The service is a domiciliary care agency (DCA) providing support to people in their own homes. At the time of the assessment there were 17 people using the service, all of which were in receipt of the regulated activity. An unannounced inspection took place on 10 and 11 September 2025 to review the quality of care and compliance with legal regulations. At the last inspection, the service was in breach of the legal regulations relating to need for consent, safe care and treatment, staffing and good governance. At this inspection, enough improvements had been made, and the provider was no longer in breach of these legal regulations. The registered manager promoted a learning culture and encouraged people to give their views to further develop the service. The registered manager was open to suggestions and addressed any concerns in a timely manner. The registered manager had a clear vision of ensuring people received a personalised service, which was adopted throughout the staff team. They ensured people were supported by a small, consistent staff team, who knew them well. This had enabled positive relationships to be built between people, their relatives and staff. People were treated with kindness and compassion, and their rights were promoted. Staff had a good understanding of consent and promoted decision making. They enabled people to live independent and healthier lives, with support from different health and social care professionals as required. Staff received regular training and were aware of their responsibilities to keep people safe. There were staff meetings and staff received regular informal and formal support. Staff were complimentary about the registered manager along with the rest of the management team. There were regular checks of staff’s performance to ensure a good standard of care was being delivered. Safe infection prevention and control practices were being followed, and people were supported to ensure their environment was safe. There were systems to ensure the safe administration of medicines which included written guidance for ‘as required medicines. This ensured medicines were consistently given for maximum effectiveness. Risks people faced were identified in care records and clear instructions of how these were managed were agreed with people and their loved ones. There was robust quality auditing systems including checks of care planning, medicine administration and staff training. We saw the actions taken by the registered manager where any errors had been identified.
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Mach Care Solutions (Birmingham) was rated Inadequate overall at its October 2022 inspection, with breaches of Regulations 9, 11, 12, 17 and 18, primarily driven by persistent missed, late and short care calls, unsafe medicines management, inadequate care planning and risk assessment, and a failure of governance systems to identify or act on these concerns. Enforcement action was taken including a Notice of Decision to impose conditions on registration, representing a deterioration from the previous Requires Improvement rating.
Concerns (12)
criticalMissed or late visits: “Sometimes they [care staff] don't come on time, sometimes they are an hour or two late... Sometimes they only stay between 10 and 16 minutes, we are paying for something we are not getting (30 minutes).”
criticalMedication management: “Some people were not given their medicines at the time they had been prescribed. This included medicine for the control of diabetes and heart conditions.”
criticalCare planning: “Care plans were not fully personalised, and information contained within them had not been reviewed and updated to reflect people's current support needs.”
criticalSafeguarding: “We found multiple examples of safeguarding concerns which had not been actioned robustly. This included the impact of people being exposed to missed calls.”
criticalStaffing levels: “Staff rotas demonstrated the provider did not always allow them travel time between calls or more than one call was scheduled at the same time.”
criticalGovernance: “Although there was a system to audit aspects of the service, we found these had failed to identify people were not supported safely in a way they chose.”
criticalPerson-centred care: “People's care and support was not always planned in partnership with them and persons close to them.”
criticalRecord keeping: “We could not be assured the system used for staff to log in and out of calls and record their notes was safe. Staff could log in to a call when they were not in attendance.”
moderateIncident learning: “Incidents had not been consistently recorded or acted on... no lessons had been learnt in a timely way for issues they had been aware of for many months, such as late calls.”
moderateConsent / capacity: “For people who were unable to make their own choices, the provider had not explored or obtained evidence people making decisions on their behalf had the necessary authority to do so.”
moderateComplaints handling: “Complaints which the provider had recorded did not reflect all the complaints people and their relatives told us they had raised.”
moderateCommunication with families: “Two people and their relatives told us some care staff members communication was limited, this was due to language barriers.”
Strengths
· Staff were aware of their safeguarding responsibilities and how to keep people safe.
· Pre-employment checks including DBS and references were in place for all staff.
· Staff received induction training in line with the Care Certificate standards.
· Many people and relatives reported staff were kind, friendly and promoted independence.
· Supervision and one-to-one meetings were in place to support staff development.
Quality-Statement breakdown (22)
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongInadequate
safe: Assessing risk, safety monitoring and managementInadequate
safe: Using medicines safelyInadequate
safe: Staffing and recruitmentInadequate
safe: Preventing and controlling infectionRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Staff working with other agencies to provide consistent, effective, timely careRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidance
Mach Care Solutions (Birmingham) remained Inadequate at its May 2023 follow-up inspection, with continued and unresolved breaches across all five key questions including unsafe medicines management, inadequate care planning, late and short calls, and retrospectively backdated audits. Enforcement action including Notices of Decision imposing conditions on registration was taken, and the service remained in special measures.
Concerns (13)
criticalMedication management: “Peoples 'as required' medication protocols were inconsistent putting them at risk of receiving too much or not enough prescribed medicines.”
criticalCare planning: “Care plans continued to lack information and guidance for staff to follow and some had not been reviewed and updated to reflect people's current support needs.”
criticalMissed or late visits: “For 1 person who required a 30 minute call, a staff member had only been in attendance for 4 minutes but had recorded they had provided full support.”
criticalSafeguarding: “People continued to be placed at risk from abuse because the systems and processes in place were not robust to keep people safe.”
criticalStaffing levels: “Staff rotas continued to demonstrate the provider did not always allow travel time between scheduled calls or more than one call was scheduled at the same time.”
criticalGovernance: “Care plan audits had not been completed between the period of June 2022 and March 2023. The registered manager told us they had completed these retrospectively.”
criticalRecord keeping: “Individual care plan audits we were provided with had been back dated from as far back as June 2022, when in fact they had all been completed in March 2023.”
criticalConsent / capacity: “The provider had continued to fail to obtain written evidence people making decisions on their behalf had the necessary authority to do so.”
criticalLeadership: “The provider has a poor history of compliance and driving or sustaining improvements within the service. This is the second inspection where multiple breaches have been identified.”
moderateStaff competency: “A staff member we spoke with told us they did not have access to a person's care plan. They could not tell us the correct support the person required.”
moderateStaff training: “We could not be assured staff had received up to date training for epilepsy, dietary needs, and catheter care as the training matrix did not reflect this.”
moderateCommunication with families: “Some staff members frequently spoke to each other in their own language, in what appeared to be raised voices. This meant the person was not aware of what was being discussed.”
moderateIncident learning: “Due to the lack of timeliness in the completion of audits we could not accurately assess the effectiveness of reflective practices.”
Strengths
· Staff were aware of their responsibilities to keep people safe from abuse.
· People and relatives confirmed staff sought consent before providing care and supported independence.
· Staff wore appropriate PPE and the provider carried out spot checks to monitor infection prevention and control practices.
· Staff received induction training in line with the Care Certificate including shadowing, online and face-to-face training.
· Most people reported being involved in the development and review of their care plans at this inspection.
Quality-Statement breakdown (21)
safe: Using medicines safelyInadequate
safe: Assessing risk, safety monitoring and managementInadequate
safe: Staffing and recruitmentInadequate
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongInadequate
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Staff support: induction, training, skills and experience