This assessment took place between 23 October and 31 October 2025. This service is a homecare agency providing personal care to adults living in their own homes. At the time of our assessment there were 25 people using the service. This specialist service 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. 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. At our last inspection of the service, the provider was in breach of regulations relating to safe care and treatment and good governance. At this assessment we checked the provider had made improvements to the service. We reviewed 21 quality statements related to the 3 key questions, ‘Is the service safe, effective and well-led? We found the provider had made improvements and was no longer in breach of regulations. Information about risks to people’s safety had improved and better managed. Staff had detailed information about how to reduce these risks and keep people safe. People’s medicines were now better managed, and they received these as prescribed. Governance systems were more effective and used regularly to check the safety and quality of the care and support provided to people. Systems were in place to protect people from risk of abuse. There were enough staff to meet people’s needs. Staff were provided with relevant training to help them meet these needs. The provider undertook checks to make sure staff recruited by the service were suitable. Infection risks were managed well and staff followed current practice. People were involved in assessments of their needs. They received person-centred care based on their individual needs. People’s care and risk management plans were reviewed regularly with them, to ensure these remained safe and effective. People were supported to stay healthy and well and received their medicines when needed. Staff made sure people understood their care, to give informed consent. The service was managed well. Staff were valued and supported with their learning, development and wellbeing. People and staff could raise concerns in confidence, and these were listened to and acted on. There was a culture of learning, inclusivity and partnership working, which helped the service continuously improve the care and support people received.
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Invicta 24 Plus, a domiciliary care agency in Croydon serving 83 people, was rated Requires Improvement overall at its June 2019 inspection, with Safe, Effective and Well-Led all requiring improvement primarily due to gaps in consent recording, inconsistent risk assessments, PRN medicines protocols and ineffective internal auditing. Caring and Responsive were rated Good, reflecting strong person-centred practice, consistent staffing, and positive feedback from people and relatives.
Concerns (6)
criticalConsent / capacity: “Care plans contained consent forms, but the ones we looked at were signed by people's relatives, by the manager of the service or not at all.”
moderateCare planning: “Some care plans contained documentation that was duplicated or out of date, and it was not always immediately clear which copy was currently in use.”
moderateMedication management: “People's care records did not contain specific instructions about what PRN medicines were prescribed for and under what circumstances they should be administered.”
moderateGovernance: “The provider's audits had failed to identify the concerns we found around a lack of evidence that people consented to their care, risk management, medicines management.”
minorRecord keeping: “Two complaints did not have a date recorded, so we were unable to check whether the provider responded within an appropriate timescale.”
minorComplaints handling: “One complaint did not have any information about what the provider had done in response.”
Strengths
· Staff built positive relationships with people and provided consistent care from familiar staff members, reducing anxiety when regular carers were absent.
· People and relatives were highly positive about the caring attitude of staff, with comments such as 'Some carers go above and beyond expectations'.
· Robust staffing and recruitment processes were in place, addressing a previous breach of Regulation 19; staff arrived on time and never missed visits.
· Staff received appropriate training, supervision, annual appraisals and a comprehensive induction before providing care.
· Care plans were person-centred, including life history, communication needs and individual preferences.
Quality-Statement breakdown (25)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
safe: Systems and processes to safeguard people from the risk of abuseGood
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
safe:Requires improvementcaring:Inspected but not ratedwell-led:Requires improvement
Invicta 24 Plus, a domiciliary care agency in Croydon serving 74 people, was rated Requires Improvement overall following a focused inspection in April 2021, with two regulatory breaches identified under Regulation 12 (safe care and treatment) and Regulation 17 (good governance). Key failings included incomplete and non-personalised risk assessments, gaps in medicines records, and governance systems that consistently identified but failed to remediate quality shortfalls across three consecutive audit cycles.
Concerns (6)
criticalMedication management: “Some medicines records were not complete, meaning we could not be fully assured people received their medicines as prescribed. Two of the records we looked at contained unexplained gaps.”
criticalGovernance: “Systems for driving service improvement were not always effective...they did not always lead to those improvements being made.”
moderateCare planning: “some risk assessments lacked the personalised detail needed to fully inform staff how to care safely for them”
moderateRecord keeping: “care log audits identified records were not detailed enough to show clearly what care and support people received, but this was noted over three consecutive audits without any evidence of action”
moderateInfection control: “Two members of staff at the office were not wearing face coverings in line with current COVID-19 guidance during our inspection.”
minorIncident learning: “one person had two recent falls recorded on incident forms but their name did not appear on the matrix, meaning the system may not always have been used effectively.”
Strengths
· Staff treated people with respect and dignity, understood their diverse needs and respected their preferences
· There were enough staff to care for people safely with an efficient and reliable system for allocating and transporting staff to care visits
· Strong safeguarding policies and procedures in place with staff demonstrating good knowledge
· Open and inclusive culture with approachable management team valued by people, relatives and staff
· Provider proactively engaged with people, relatives and staff through regular surveys and quality monitoring
Quality-Statement breakdown (12)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Preventing and controlling infectionRequires improvement
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Learning lessons when things go wrongRequires improvement
caring: Ensuring people are well treated and supported; respecting equality and diversityInspected but not rated
well-led: Continuous learning and improving careRequires improvement
Invicta 24 Plus, a newly registered domiciliary care agency serving 12 people in Bromley and Bexley, received Good ratings across all five key questions at its first inspection in August 2015. The service demonstrated strong person-centred care, robust safeguarding and medication management, and effective leadership, with only a minor record-keeping shortfall identified and promptly addressed by management.
Concerns (1)
minorRecord keeping: “We noted in two of the daily records the information was too brief and did not give a full picture of how the person had responded to the care provided”
Strengths
· People felt safe and reported staff arrived on time and stayed for the agreed period
· Effective recruitment procedures including DBS checks, identity verification, and references
· Comprehensive training programme aligned to the Care Certificate framework
· Staff demonstrated good understanding of Mental Capacity Act 2005 and applied it in practice
· Medication procedures were robust with staff trained and assessed as competent
Invicta 24 Plus is a domiciliary care agency rated Good overall, with a Requires Improvement rating for Safe due to incomplete pre-employment references in two of six staff files reviewed. All other key questions were rated Good, with inspectors noting a well-organised, person-centred service supported by a visible and responsive management team.
Concerns (2)
moderateStaffing levels: “Recruitment systems were not fully robust at the agency. Of the six staff records we examined two of these did not contain previous employment references.”
minorRecord keeping: “We shared with the provider the importance of compliance checks and audits in other areas such as staff files.”
Strengths
· People felt safe and reported reliable, punctual visits from consistent care staff
· Risk assessments were thorough, regularly reviewed, and available in people's homes and at the office
· All staff trained and assessed as competent in medicines administration with individual medication profiles in place
· Strong staff training programme covering dementia, safeguarding, moving and handling, infection control and food hygiene
· Mental Capacity Act 2005 understood and applied correctly by registered manager and staff
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: End of life care and supportGood
well-led: Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candour; managers and staff being clear about their rolesGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Working in partnership with othersGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
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 staffGood