Date of Inspection: 06 January to 26 January 2026. The inspection included two site visits which took place on the 06 and 14 January 2026, with additional information and evidence reviewed remotely. We looked at 5 key questions: Safe, Effective, Caring, Responsive and Well-led. Excellence Healthcare is a domiciliary care agency and provides personal care to people living in their own homes, including people living with dementia, people with sensory impairment, people with physical disabilities and autistic people or people with a learning disability. CQC only inspects where people are receiving the regulated activity personal care. This is help with tasks related to personal hygiene and eating. Where they do, we consider any wider social care provided. At the time of this inspection 4 people were receiving support with personal care. Although the service was not supporting autistic people or people with a learning disability at the time of our assessment, we assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group. The assessment was prompted because of the length of time since our last inspection in 2018. We found 3 breaches of regulation in relation to safe care and treatment, staffing, and good governance. We looked at all 5 key questions: Safe, Effective, Caring, Responsive and Well-led. The provider had governance systems in place to monitor and improve the quality of the service, but these were not always effective. Care plans and risk assessments were in place to support people to manage risks. These needed some development, for risks to be managed effectively, and so staff had the guidance needed to support people safely. Recruitment checks were in place to help ensure staff employed were suitable to care for people. However, the provider did not complete all the required pre-employment checks on staff who had worked in care before, to ensure their suitability for the role. This meant there was a risk that people might receive care from unsuitable staff. Right Support - Staff ensured they communicated and shared information with people in a way they could understand. People were encouraged to maintain relationships with family and friends. Governance systems and audits were not always effective in identifying or addressing areas for improvement. New staff were not always recruited robustly. Right Care - Staff followed current best practice guidelines regarding infection prevention and control. People told us staff were kind and caring and staff protected their privacy and dignity. Right culture – Governance systems were not robust. People spoke highly of staff members. Staff understood people and their needs well, and escalated concerns appropriately. Staff received safeguarding training and understood their roles in protecting people from the risk of abuse or avoidable harm. The provider raised and escalated safeguarding’s and concerns about people’s needs effectively. The provider told us they would take action to address concerns raised during the inspection. We have asked the provider for an action plan in response to the concerns found at this assessment.
PDF cached but not yet analysed by Claude; set ANTHROPIC_API_KEY and re-run npm run etl:reports -- --location 1-2041181060.
Excellence Healthcare improved from Requires Improvement to Good overall since its January 2017 inspection, with people reporting feeling safe, well-cared for, and supported by consistent, trained staff. The Well-Led domain remains Requires Improvement due to inconsistent record-keeping, a failure to notify CQC of a safeguarding incident, and gaps in the provider's DoLS knowledge.
Concerns (5)
criticalGovernance: “a safeguarding raised by a professional...all appropriate actions had been taken, with the exception of notifying the CQC.”
moderateRecord keeping: “environmental risk assessments in people's care files were not dated and in one we found some information that was incorrect.”
moderateCare planning: “one risk assessment referred to a family member supporting a person with their medication but the family member had passed away.”
moderateConsent / capacity: “their knowledge of DoLS, although slightly improved, required further improvement to ensure the provider understood their legal obligation.”
minorCare planning: “this information could be enhanced to include, for example, symptoms when a person with diabetes had low blood sugars.”
Strengths
· People felt safe with staff and reported no missed or late visits; staff arrived on time consistently.
· Safe recruitment practices including DBS checks and references were in place.
· Staff received mandatory training including safeguarding, moving and handling, infection control, and the Care Certificate.
· Staff received regular supervision with spot checks completed in people's homes.
· People were supported by consistent, small teams of carers promoting continuity of care.
Excellence Healthcare received an overall rating of Requires Improvement at this January 2017 inspection, with four of five key questions requiring improvement and a regulatory breach of Regulation 17 (Good Governance) identified due to ineffective quality monitoring, poor record keeping, and unresolved medication management failures. Some progress had been made since the previous inspection in January 2016, notably in staff training and recruitment, but critical concerns around medication administration, DoLS awareness, risk assessment quality, and governance systems remained unaddressed.
Concerns (10)
criticalMedication management: “Doesn't always get it through the night when [staff] are here because they don't like giving it”
criticalMedication management: “MAR charts did not utilise the key code appropriately, lacked detail and did not appear to follow protocol in accordance with the person's care needs”
criticalSafeguarding: “During our discussions with relatives, we identified a potential safeguarding issue that we referred to the local authority, who are responsible for investigating safeguarding concerns.”
criticalConsent / capacity: “The provider was unable to articulate their understanding of DoLS and was not aware of their reporting responsibilities.”
criticalGovernance: “Collectively, this is a breach of regulation 17 of the Health and Social Care 2008 (Regulated Activities) Regulations 2014 relating to the lack of governance within the service.”
moderateRecord keeping: “risk assessments we looked at were not always specific to people's health related care needs and did not always reflect the information that had been provided in the social worker's initial assessment”
moderateGovernance: “audits did not identify the shortfalls we found during our inspection. For example, audits of the care records did not identify the issues relating to medication care plans, risk assessments or protocols.”
moderateCare planning: “this information was not included in their risk assessment or care plans and there was no guidance to staff on how they could support the person to manage or prevent these incidents”
moderateIncident learning: “daily record logs consistently reported a person to be complaining of persistent pain...This had not been identified by the provider.”
moderateLeadership: “the provider had failed to respond to some areas of our feedback at our last inspection...shortfalls with insufficient and unspecific risk assessments and care plans”
Strengths
· Safer recruitment processes had improved since the last inspection, including formal interviews, references, and DBS checks.
· Staff training had improved, with a comprehensive training programme and induction including shadowing and competency checks.
· Staff understood safeguarding responsibilities and knew how to report concerns internally and externally.
· People were supported by kind, caring and consistent staff who knew them well and promoted their independence.
· People were actively involved in the planning and reviewing of their care.
Quality-Statement breakdown (16)
safe: Risk assessments and risk management plansRequires improvement
Excellence Healthcare, a newly registered domiciliary care provider in Birmingham, was rated Requires Improvement overall at its first inspection in January 2016, with staff routinely providing medication support and personal care without having received the required training or formal induction. While people spoke positively about individual carers and felt safe and respected, systemic weaknesses in governance, staff training, supervision, and policy implementation meant the service was not consistently meeting its legal obligations.
Concerns (8)
criticalMedication management: “staff were supporting people to take their medications without the relevant training to do so...I had not done anything before hand for about 11 years; I needed a refresher”
criticalStaff training: “staff had not been trained effectively prior to undertaking home care calls independently...my induction was just shadowing [staff member] for three days”
moderateSupervision / appraisal: “They told us that they did not receive any formal or planned supervision sessions with the registered manager and that the provider does not hold team meetings.”
moderateGovernance: “medication audits did not identify gaps in medication records and the MAR charts did not utilise the key code appropriately and lacked detail”
moderateCare planning: “risk assessments...did not always include detailed management plans with guidance for staff on what action to take should the risk occur”
moderateLeadership: “the service did not always have the required resources readily available to enable them to meet their legal requirements particularly those relating to staff development and training”
moderateStaff competency: “some staff files did not have copies of previous training and staff members were actively providing care without the registered manager being assured of their knowledge and skills”
minorRecord keeping: “some of the care plans were copied directly from the social care needs assessment and therefore did not reflect the independent assessment facilitated by the provider”
Strengths
· People felt safe and staff understood different types of abuse and reporting procedures
· Staff were described as kind, friendly, caring and treated people with dignity and respect
· Consistent care staff allocation, enabling positive relationships to develop with people
· People were actively involved in planning their own care and felt in control