Date of assessment 03 July to 17 July 2025. Tamworth Homecare Limited is a domiciliary care agency registered to provide personal care to people in their own homes. The service is registered to provide support to children aged 4 to 18 years, people with a sensory impairment, physical disability and younger and older adults. Some of whom are living with dementia. At the time of our assessment the service supported 114 people, some of those people received 24-hour care and support. While the service is registered to support people with a learning disability, they were not supporting anyone who’s primary need was their learning disability at the time of our inspection. The last rating for this service was inadequate (report published 10 April 2025). We identified 3 breaches of the regulations in relation to safe care and treatment, staffing and governance, and a warning notice was served due to the provider’s failure to meet these legal regulations. We undertook this inspection to check improvements had been made and to confirm they now met legal requirements. Improvements were found at this inspection and the provider was no longer in breach of these regulations. This service has been in Special Measures since 10 April 2025. The provider demonstrated improvements had been made. The service is no longer rated inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures. Quality assurance systems and processes had improved since our last inspection, although further time was needed for these to fully embed to ensure they were sustained. Staff had received training for their roles; however, the quality of some of this training needed to be reviewed based on the mixed feedback we received. Risks associated with people’s care were assessed and staff understood their responsibilities to keep people safe. Care records informed staff, for example if a person had capacity to make their own decisions or not. Staff supported people in the least restrictive way possible and in their best interests. The staff worked in partnership with other professionals to achieve good outcomes for people. Staff were recruited safely, and medicines were administered as prescribed, by staff trained in medicines management.
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Date of assessment: 12 and 13 November 2024. We undertook this assessment because we had received some information of concern from members of the public about the service. Tamworth Homecare Limited is a domiciliary care agency providing personal care to people in their homes. The service is registered to provide support to children aged 4 years to 18 years, to people with a learning disability, autistic people, people with a sensory impairment or physical disability and people with dementia and younger and older adults. At the time of our assessment, 139 people were being supported and their primary need was personal care. People had individual packages of care ranging from 30-minute care calls to 24-hour care and support. The last rating for this service was requires improvement (report published 23 August 2023). We identified 3 breaches of the regulations relating to safe care and treatment, staffing and governance. We took enforcement action and served a warning notice to the provider. At this assessment we found minimal improvements had been made to address breaches of regulations we identified to the provider at our last inspection and other areas had deteriorated which put people at continued risk of harm. A review of 18 people’s care records confirmed staff did not always have detailed information about people’s health conditions, how to manage these and actions to take in the event of deterioration. Some medicine practices were not safely managed in line with the manufacturer’s directions. People were not always protected from risks associated with their care because staff did not always have the skills they needed because effective training had not always taken place. There were significant failings in the governance of the service. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and / or appeals have been concluded.
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Tamworth Home Care Limited received an all-domain 'Requires Improvement' rating at its July 2023 inspection, with regulatory breaches identified in safe care and treatment (Reg. 12), fit and proper persons employed (Reg. 19), and good governance (Reg. 17, subject to a Warning Notice). Persistent failures in risk assessment, staff recruitment checks, care plan personalisation, complaints handling, and governance oversight meant the service had not improved since its previous 'Requires Improvement' rating published in March 2023.
Concerns (15)
criticalCare planning: “We found no detailed guidance to inform staff how to safely attach a hoist sling for 1 person who used a hoist for transfers.”
criticalRecord keeping: “1 person was dependent on staff for all their hydration and nutritional needs but ate and drank very small amounts. This person had no risk management plan.”
criticalSafeguarding: “We found no investigation record related to a specific allegation and no actions to put safeguards in place.”
criticalStaff training: “One staff member told us, 'I support a person with a learning disability but have not done training in this.'”
criticalStaff competency: “The provider's moving and handling trainer had not ensured staff were always taught how to safely use equipment in people's own homes.”
criticalGovernance: “Their last audit dated May 2023 recorded 'all staff files are up to date', which we found they were not.”
criticalGovernance: “The registered provider and registered manager had not always effectively assessed, monitored or improved the quality and safety of the services provided.”
criticalIncident learning: “The registered manager confirmed they had been made aware of this 4 days prior to our inspection. However, the registered manager confirmed they had taken no action to investigate.”
moderateStaffing levels: “Some staff told us that they did not have time to take a break to eat or drink between their morning care calls and starting their lunchtime care calls.”
moderateSupervision / appraisal: “Checks on staff's skills took place... they might not have their competency assessed whilst supporting a person in their home until 3 months later.”
moderateRecord keeping: “The training matrix did not record the actual dates training had been completed by staff, but only the date when topics were next due.”
moderateComplaints handling: “Numerous people and relatives shared examples of feeling they were not listened to by the registered manager or senior care staff and their concerns were not resolved.”
moderateLeadership: “In the absence of the registered manager, there was no staff member with delegated responsibility in the office to deputise for them.”
minorPerson-centred care: “One person, who did not have a catheter, had detailed information for staff to follow about caring for a catheter.”
minorCommunication with families: “Not everyone knew they could request access to the electronic 'app' for their care plan. One relative told us, 'I didn't know I could have access.'”
Strengths
· Staff had completed training in the safe handling of medicines and medicine administration records showed people had received their medicines as prescribed.
· Improvements had been made to PPE usage; staff had access to stocks of PPE and used these when supporting people with personal care.
· Improvements had been made to introduce body maps to ensure people prescribed transdermal patches received medicines safely.
· Staff respected and promoted people's privacy, dignity and independence during personal care.
· Staff worked within the principles of the Mental Capacity Act and understood the importance of gaining consent.
Quality-Statement breakdown (20)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Using medicines safelyRequires improvement
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Staff work with other agencies to provide consistent, effective, timely careRequires improvement
Tamworth Home Care Limited requires improvement overall, with key failures in medicines management — particularly transdermal patch application not following manufacturer guidance — and inconsistent infection prevention practice by staff. Strengths include a caring culture, safe recruitment, detailed personalised care planning, and effective working relationships with healthcare professionals.
Concerns (6)
criticalMedication management: “Transdermal (skin) patch medicines were not always applied to people's skin in line with the manufacturer's directions for safe use.”
moderateMedication management: “Body maps were not in place where people had transdermal patch medicines...the recording system in place was ineffective in ensuring safe practices were followed.”
moderateInfection control: “Staff did not always follow directions given to them by the registered manager about infection prevention and the use of personal protective equipment (PPE).”
moderateGovernance: “Checks on people's medicine administration records (MARs) completed by the registered manager had not identified shortfalls we found related to medicines administered through transdermal (skin) patches.”
minorGovernance: “The registered manager's directives and reminders to staff had not always had the desired outcome...feedback demonstrated this remained an area for improvement.”
minorCommunication with families: “A few told us they had not always received a call to inform them of a late care call.”
Strengths
· Risks of harm were identified and detailed risk management plans were available to staff, with recognised tools used to assess specific areas of risk.
· Staff were recruited safely with DBS checks and references; sufficient staff were employed with no missed calls reported.
· People and relatives gave consistently positive feedback about the caring, kind and considerate approach of staff.
· Care plans were detailed, personalised and regularly reviewed and updated when people's needs changed.
· Mental capacity assessments had been completed where required, with improvements made since last inspection.
Quality-Statement breakdown (21)
safe: Preventing and controlling infectionRequires improvement
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Learning lessons when things go wrongGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Staff support: induction, training, skills and experienceGood