Date of Assessment: 10 February 2026 to 11 February 2026. The service is a domiciliary care agency providing personal care to adults of all ages living with dementia. sensory impairment, physical disabilities and mental health conditions. This assessment was completed to identify if the required improvements had been made following a previous inspection. We found improvements had been made. People received safe care that was based on their individual needs. Infection control was considered. Medicines were managed safely. People were protected from potential abuse as procedures were in place. The principles of the Mental Capacity Act were understood. Staff, who had been safely recruited had the skills and knowledge to support people and deliver care at the times people needed it. People were happy with the staff who supported them and felt they were treated in a caring way. Staff felt listened to and involved with the service. However, improvements were needed to ensure governance systems were clearly recorded and care plans and risk assessments contained all the information required to keep people safe and to ensure care was delivered in line with individual preferences.
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Our Care Ltd, a small domiciliary care service in Wolverhampton, improved from the previous inspection with Safe rising to Good following resolution of prior breaches in risk management and medicines administration. Well-led remains Requires Improvement as governance and audit systems, while strengthened, are not yet fully embedded to provide comprehensive service oversight; a recommendation was made to develop audit processes.
Concerns (1)
moderateGovernance: “further improvements were still required to ensure the systems were well established and that governance processes could be used to provide regular oversight into the overall quality of care provided.”
Strengths
· Improvements made to medicines management; topical medicines now recorded on MAR and controlled drugs safely administered
· Risk information now included in care plans; staff aware of individual risks and how to manage them
· Consistent staffing team; people report no missed visits and staff arriving on time
· Learning following incidents has improved; nominated individual directly involved in reviewing and acting on events
· Staff follow infection control guidance and use PPE appropriately
Quality-Statement breakdown (10)
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Learning lessons when things go wrongGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: How the provider understands and acts on the duty of candourGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empowering; Engaging and involving people and staffGood
Our Care Ltd received an overall rating of Requires Improvement, with continued breaches of Regulation 12 (safe care and treatment) and Regulation 17 (good governance) due to unsafe medicines administration, absent or inadequate care plans and risk assessments, and ineffective quality assurance systems. While staff were consistently praised for their kind and caring approach and improvements in staffing and complaints handling were noted, the provider failed to make the required improvements identified at the previous inspection in April 2020.
Concerns (11)
criticalMedication management: “staff were administering morphine to a person without this being recorded on their medicine's records...staff had not got clear instructions on when or how this was to be given”
criticalMedication management: “staff were applying people's creams without confirmation these were prescribed and these being recorded on people's medicines records. Staff had recorded applying unnamed creams to one person on 8 occasions.”
criticalCare planning: “one person had a pressure area on their skin and had no guidance in place to support staff to meet this need. This placed them at risk of not receiving care in line with this need”
criticalCare planning: “people with diabetes had no care plans and risk assessments in place to reflect this...staff did not have clear guidance on how to identify signs of deterioration”
criticalGovernance: “there was no oversight of how medicines records are completed and maintained...The provider had no system in place to monitor people's care records to ensure these remained accurate”
criticalIncident learning: “the provider had failed to review all alerts and take action to ensure improvements were made...a person had 2 alerts that had not been actioned on their care records in relation to their skin integrity”
criticalSafeguarding: “The provider did not always notify CQC of potential safeguarding incidents at the service as they were required to do so. For example, we found 2 safeguarding referrals the provider had not notified us about.”
criticalRecord keeping: “staff were not always clear on the amount of thickener this person required to support them to drink safely. This placed the person at increased risk of choking.”
moderateCare planning: “a person living with dementia had no reference to this within their care plan to ensure staff understood how this impacted the person and how they were treated.”
moderatePerson-centred care: “a person's care plan advised staff were to prompt the person with their medicines but not to administer them. However, staff were recording they had administered these medicines. This did not promote their independence.”
moderateCommunication with families: “People's communication needs were not always recorded within their care records...having no guidance in place...placed people at risk of not consistently receiving care in line with these”
Strengths
· People received care at times they preferred from regular staff who knew them well, with sufficient time at each visit.
· Staff were described as 'kind' and 'caring' by people and relatives; dignity, privacy and independence were promoted.
· Safe recruitment practices were in place including DBS checks.
· Staff received induction, Care Certificate and shadowing before working independently.
· Complaints handling had improved since last inspection; the provider was no longer in breach of Regulation 16.
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
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 guidance
Our Care Ltd, a domiciliary care service in Wolverhampton, was rated Requires Improvement overall (Inadequate for Well-Led) following a March 2020 inspection, with warning notices issued for breaches of Regulations 12 and 17 relating to unsafe medicines management and ineffective governance. The service had deteriorated from Good since its last inspection in 2017, driven by rapid growth that overwhelmed leadership capacity, resulting in persistent late calls, poor record-keeping, and an ineffective complaints system.
Concerns (14)
criticalMedication management: “Staff did not use the provider's E-MAR system or paper MAR charts to record the administration of medicines or creams.”
criticalMedication management: “No audits of medicines had been carried out since December 2019 and the provider had not been aware of the concerns we identified.”
criticalCare planning: “One person's pre-existing assessment had not been reviewed since they were referred to the service in January 2020.”
criticalGovernance: “Systems to monitor and assess the quality and safety of the service were not effective and had resulted in breaches of the regulations.”
criticalComplaints handling: “They discovered a misfiled complaint when searching for other records we requested. This did not assure us that complaints were consistently recorded.”
criticalRecord keeping: “Medicines administration records had not been completed since December 2019 and a mixture of electronic and paper-based records were being used.”
moderateMissed or late visits: “They should come at 8am but they sometimes don't come till 11am and at night they don't get here till 11pm, when they should be here at 9pm.”
moderateMissed or late visits: “Care calls were not always planned to allow travelling time, which meant staff frequently ran late and people sometimes felt their care was rushed.”
moderateGovernance: “The provider's call monitoring system was limited to sending an email alert for each individual call. This meant the provider did not monitor punctuality across the service.”
moderateComplaints handling: “The provider did not record informal complaints or grievances and told us they were unaware of the complaint raised with us.”
moderateIncident learning: “Whilst the provider told us investigations were carried out and learning shared with staff, they were unable to provide evidence to support this.”
moderateLeadership: “The provider was struggling to balance the demands of managing the safety and quality of the service, whilst regularly covering care calls.”
moderateStaffing levels: “The provider did not have a systematic approach to determining the number of staff needed to maintain a consistently reliable service.”
minorPerson-centred care: “People did not always receive personalised care that met their preferences; care calls were not always at their preferred times or delivered by consistent care staff.”
Strengths
· Staff were recruited safely with appropriate pre-employment checks.
· Staff completed induction, Care Certificate, and ongoing relevant training including specialist training such as PEG feeding.
· Staff received ongoing supervision and an annual appraisal.
· People had good relationships with regular staff and spoke positively about them.
· Staff supported people to access healthcare services and understood when to escalate health concerns.
Quality-Statement breakdown (23)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Staff support: induction, training, skills and experience
Our Care Ltd, a small Wolverhampton domiciliary care agency supporting 18 people, was rated Good across all five key questions at its first comprehensive inspection in August 2017. The main areas for improvement were gaps in MAR sheet completion between April and July 2017 and an insufficiently updated moving and handling risk assessment, though both were being actively addressed by the registered manager.
Concerns (3)
moderateRecord keeping: “medication administration records (MAR) completed by care workers between April and July 2017 contained gaps in the MARs. The gaps in the MARs meant it was not clear if people had received their medicines as prescribed.”
moderateMedication management: “audits regarding medication administration had picked up errors regarding medication however the actions taken to reduce the errors had not been completely effective.”
minorCare planning: “the movement and handling risk assessment had not been updated to give clear instruction to care workers regarding the additional risks involved in assisting the person to undertake gentle exercise.”
Strengths
· People felt safe with regular care workers, with strong consistency of staffing minimising exposure to unfamiliar workers.
· Robust pre-employment checks including DBS renewals for longstanding staff.
· Structured induction including Care Certificate and supervised shadowing before independent working.
· Regular supervisions every two months and annual appraisals for all care workers.
· Care workers trained and assessed as competent in medication administration.
Quality-Statement breakdown (15)
safe: Risk assessmentsGood
safe: Medicines managementGood
safe: SafeguardingGood
safe: RecruitmentGood
safe: Staffing and missed callsGood
effective: Staff training and inductionGood
effective: Supervision and appraisalGood
effective: Mental Capacity Act / consentGood
Good
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires improvement
effective: Staff working with other agencies to provide consistent, effective, timely careRequires improvement
effective: Staff support: induction, training, skills and experienceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityRequires improvement
caring: Respecting and promoting people's privacy, dignity and independenceRequires improvement
caring: Supporting people to express their views and be involved in making decisions about their careGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesRequires improvement
responsive: Meeting people's communication needsRequires improvement
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: How the provider understands and acts on the duty of candourRequires improvement
well-led: Working in partnership with othersRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
Good
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: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Respecting and promoting people's privacy, dignity and independenceRequires improvement
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: Planning personalised care to ensure people have choice and controlRequires improvement
responsive: End of life care and supportGood
responsive: Meeting people's communication needsRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsInadequate
well-led: How the provider understands and acts on the duty of candourRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Engaging and involving people using the service, the public and staffInadequate
well-led: Continuous learning and improving care; Working in partnership with othersRequires improvement