Date of assessment: 19 August to 27 August 2025. This service is a domiciliary care service, registered to provide personal care for people living in their own homes in the community. They provide support to people with a range of different needs including older people, younger people, people with dementia and people with a learning disability. Not everyone who uses a domiciliary care service receives personal care. CQC only inspects where people receive personal care. An assessment has been undertaken of a specialist service that is registered for use by autistic people or people with a learning disability. At the time of the assessment, the service was not used by anyone with a learning disability or an autistic person for personal care. However, we assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group. This assessment was to check on action we asked the provider to take at our last visit. We rated this service under our previous methodology in October 2023 where it was inspected and rated as requires improvement overall. We found breaches of regulations in safe care and treatment and good governance. At this assessment the provider remained overall requires improvement. The provider remained in breach of the legal regulations relating to safe care and treatment and good governance. The provider did not have effective governance systems demonstrating clear management and oversight of the service. Quality monitoring and auditing was not sufficiently robust and had not identified the concerns found during the assessment. Where quality audits had been completed, these failed to demonstrate they were meaningful and effective. Some aspects of the service, such as care plans and medicines, were not robustly audited. People’s medicines were not always managed safely. Risk assessments were not always in place to mitigate risks to people. Some Care plans to guide staff practice about how to manage risks, lacked sufficient information to tell staff what they must do to manage the risks and what a change of need may look like for individuals. Accidents and incidents were investigated and actions were taken, however the provider failed to record any lessons learnt to mitigate the risk of re-occurrence. Whilst we found no evidence of negative impact on people using the service, systems were not robust enough to fully protect people from potential risk of harm. Staff were recruited safely and felt supported within their role. Staff built up a good rapport with people and delivered care with kindness and compassion. People were supported by staff to have maximum choice and control of their lives. The provider welcomed our feedback and said they would take actions to make improvements. We have asked the provider for an action plan in response to some of the concerns found at this assessment. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website.
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2M Health & Home Care Services Ltd improved from Inadequate to Requires Improvement across Safe, Effective, and Well-led domains following a focused inspection on 19 September 2023, exiting Special Measures. Continued breaches of Regulations 12 and 17 were identified, relating to risk management deficiencies including missing anticoagulant risk assessments, inadequate care plan detail, and ineffective governance systems including no oversight of electronic call monitoring showing 17% of calls were late.
Concerns (8)
criticalMedication management — “The provider did not have risk assessments for people prescribed anticoagulant medicines. People's preferred method of taking their medicine, support required or confirmation of their level of compliance was not always recorded.”
criticalGovernance — “The provider did not have systems to review electronic call monitoring (ECM) records... 17% of calls were late.”
criticalSafeguarding — “Staff performed restrictive practises without the authority or guidance to do so.”
moderateCare planning — “Care plans continued to lack information about the support people needed and their preferences. Medicines related documents were completed correctly, however medicines care plans required improvement.”
moderateRecord keeping — “Oversight of care records had failed to identify that some care plans did not contain enough detail... no guidance or detail for staff as to what the person's target blood sugar range should be.”
moderateConsent / capacity — “The questions asked as part of the assessment were not recorded to provide clear evidence about whether the person had capacity or not.”
moderatePerson-centred care — “The provider failed to ensure staff had full access to people's care records. There was no system in place to identify whether records were present at the person's home.”
minorComplaints handling — “There was no evidence or record of the response given to the complainant to ensure it had been responded to satisfactorily.”
Strengths
· Safeguarding systems improved; staff well informed in how to keep people safe and able to recognise signs of abuse.
· Safe recruitment practices in place including DBS checks, employment references, proof of identification and right to work.
· Staff received medicines training and had their competency checked to ensure they were safe to administer medicines.
· Staff completed mandatory training including equality and diversity, moving and handling, safeguarding, MCA, medicines administration, and first aid.
· Staff received regular supervisions, appraisals and induction with shadowing.
Quality-Statement breakdown (13)
safe: Assessing risk, safety monitoring and management; Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experience
2M Health & Home Care Services Ltd was rated Inadequate overall following a May 2023 inspection, with breaches across six regulations including safe care and treatment, safeguarding, consent, staffing, governance and person-centred care. The service was placed in special measures due to widespread failures in medication management, risk assessment, staff training, recruitment checks and leadership oversight.
Concerns (16)
criticalMedication management — “7 staff members had not completed mandatory medication training. The registered manager and field care supervisor told us, competency assessments for medicine administration had never been completed.”
criticalCare planning — “Care plans and risk assessments were not comprehensive and lacked detail about people's care and health needs.”
criticalSafeguarding — “During the inspection, an incident occurred. The provider had failed to record the incident or report it to the relevant agencies.”
criticalStaff training — “Staff training records showed not all staff had completed the full mandatory training modules before carrying out care calls.”
criticalStaff competency — “The provider had failed to assess the effectiveness of the training given to staff. For example, competency assessments had not been completed for any staff member.”
criticalGovernance — “The provider did not undertake robust auditing of the systems and governance across the service. Therefore, they had not highlighted the shortfalls we identified.”
criticalConsent / capacity — “Mental capacity assessments had not been completed by the provider to determine people's ability to make particular decisions.”
criticalRecord keeping — “The provider failed to identify 10 staff members to the inspection team. The provider was unable to provide any recruitment records for 6 of these staff members.”
criticalLeadership — “The registered manager did not have an adequate understanding of their role, regulatory requirements and lacked oversight of the service.”
moderateIncident learning — “There were no formal records documenting trends and patterns of incidents or how lessons learned were used to reduce risk or improve services.”
moderatePerson-centred care — “People did not always have person-centred care plans in place to guide staff and ensure they received personalised care.”
moderateEnd-of-life care — “Care plans we reviewed contained vague references to funeral arrangements under the section 'end of life wishes'. This meant people's wishes and preferences may not be met.”
moderateCommunication with families — “Several relatives told us there has been ongoing problems with language barriers, and people are not consistently supported by familiar care staff.”
moderateComplaints handling — “There was no evidence to show complaints had been analysed for themes or trends, to enable preventative work, or service improvements to be identified.”
moderateInfection control — “The provider was unable to evidence all staff had completed training in infection prevention and control (IPC). This posed a risk in relation to managing and minimising the risk of infection.”
moderateMissed or late visits — “I asked for specific call times, but [Care Staff] come when it suits them. I can't rely on [Care Staff] for medication as they turn up at odd times.”
Strengths
· A registered manager was in post at the time of inspection.
· Staff meetings were taking place and the information discussed was relevant.
· Most people reported care staff wore appropriate PPE and followed safe practices.
· Relatives were generally positive about care staff being respectful and maintaining privacy and dignity.
· Following the inspection, the registered manager instructed an external organisation to work with them to drive improvements.
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and managementInadequate
safe: Using medicines safelyInadequate
safe: Systems and processes to safeguard people from the risk of abuseInadequate
safe: Staffing and recruitmentInadequate
safe: Learning lessons when things go wrongRequires improvement
safe: Preventing and controlling infectionRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Assessing people's needs and choices; supporting people to eat and drinkRequires improvement
Good
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Working in partnership with othersGood
effective: Staff support, training, skills and experienceRequires improvement
effective: Staff working with other agencies to provide consistent, effective, timely careRequires improvement
caring: Supporting people to express their views and be involved in making decisions about their careRequires improvement
caring: Respecting and promoting people's privacy, dignity and independenceRequires improvement
caring: Ensuring people are well treated and supported; respecting equality and diversityRequires improvement