Date of Assessment: 15 December 2025 to 19 January 2026. Farecare Gloucestershire Limited is a homecare agency providing personal care to 18 people. At the time of the assessment 12 people were being supported with the regulated activity of personal care. At our previous inspection we had found breaches in regulation. At this inspection we found improvements had been made related to safe care and treatment, governance and recruitment and the service was no longer in breach of the regulations. People’s needs were assessed prior to admission. Staff worked well with external professionals to ensure continuity of care. Staff received training to meet people’s needs. Staff knew people well and promoted their independence. Staff were very positive about the leadership team at the service and felt supported. There were enough staff to meet people’s needs. Governance systems had improved and the provider had begun implementing required checks and audits, however further time was needed to embed these. People’s risk assessments were in the process of being completed with improvements being made to make them more person-centred. There was a process in place to ensure these were regularly reviewed. The provider acted following our inspection to ensure concerns raised were rectified. Improvements to how recruitment records were stored was needed to ensure effective auditing could take place. Assessments of people’s mental capacity were not being completed. This meant people’s needs if they became confused or refused care were not being assessed. Staff had received training on the Mental Capacity Act 2005 and understood the principles; however, records were not in place to support staff when delivering care.
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Date of assessment; 05 February 2025 to 06 February 2025. The service is a domiciliary care agency providing personal care to people living with physical health needs and dementia in their own homes. At the time of our inspection there were 26 people receiving a regulated activity. The assessment was completed due to concerns we received about the service. The service has been rated inadequate. We identified 4 breaches of regulations, 3 repeated breaches and 1 new breach. People were not supported to have maximum choice and control of their lives and staff did not support them in their best interests; the policies and systems in the service did not support safe practice. There were concerns around risk to people and how these were assessed and managed. Support plans and risk assessments were not completed to ensure people were receiving care which met their current needs. Medicines were not always administered safely, and people did not always receive them as prescribed. Staff were not recruited safely and did not always have the qualifications, skills, competencies and experience to carry out their role. The leadership, governance and culture did not promote the delivery of high-quality, person-centred care. The provider did not have consistent leadership and the management team, and senior staff were unclear about what their roles were. At the time of our inspection the service did not have a registered manager in place. For instances where CQC have decided to take civil enforcement action against a provider, we will publish this information on our website after any representations and/or appeal have been concluded. The service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of care provided.
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Farecare Gloucestershire Limited received an overall rating of Requires Improvement following a focused inspection of the Safe and Well-led domains, with the service remaining in breach of Regulations 12, 17, and 19 due to inadequate risk documentation, unsafe medicines management, and unsafe recruitment practices. Whilst staff and leadership demonstrated positive attitudes and some immediate corrective actions were taken during inspection, the provider's improvement plan remained incomplete and governance systems were insufficient to identify and address all quality and safety shortfalls.
Concerns (9)
criticalCare planning: “the support requirements for one person with epilepsy had not been identified and recorded. Therefore, staff may not fully understand how to support the person safely”
criticalMedication management: “Systems were not in place to guide staff in safely administering 'as required' medicines...This put people at risk of not receiving their "as required" medicines safely.”
criticalStaff competency: “recruitment records did not always show that the recruiting managers had explored the previous employment histories of staff and their suitability to work at in the service.”
criticalGovernance: “The systems implemented by the provider to help monitor the service had not always been effective in identifying and addressing quality and safety shortfalls in the service.”
moderateMedication management: “information was not always recorded to guide staff in relation to the area this had been applied to so they can ensure correct rotation of the patch.”
moderateRecord keeping: “Environmental risk assessments of people's home were not consistently available on the electronic system or lacked detail.”
moderateGovernance: “there was no system in place for documenting and auditing the findings in relation to care calls; including punctuality, cancelations and calls outside planned times.”
moderateSupervision / appraisal: “further development was required to ensure there was a system in place which provided a clear overview of staff's mandatory training”
minorCommunication with families: “mixed feedback from people and their relatives in relation to the communication with the office, such as not knowing who the manager was, who to contact and not always being contacted back.”
Strengths
· Staff understood their responsibility to report concerns and poor practices, and knew how to report incidents or accidents.
· Staff had been trained in safeguarding and knew how to report concerns in line with policies and procedures.
· People and relatives reported feeling safe and well cared for by the service.
· Staff had access to sufficient PPE stock and used it correctly.
· A new accident and incident form was created with more in-depth details including a management review section.
Quality-Statement breakdown (9)
safe: Assessing risk, safety monitoring and management; Using medicines safelyRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
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: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
How the provider understands and acts on the duty of candour
Farecare Gloucestershire Limited was rated Requires Improvement overall following a focused inspection of the Safe and Well-led key questions, with three regulatory breaches identified covering safe care and treatment (Reg 12), good governance (Reg 17), and fit and proper persons employed (Reg 19). While people reported feeling safe and staff demonstrated good safeguarding awareness, significant shortfalls were found in risk assessment documentation, medicines management, safe recruitment practices, and the effectiveness of governance audits.
Concerns (7)
criticalCare planning: “The assessment and support requirements for one person with diabetes had not been identified and recorded. Therefore, staff may not fully understand how to support the person safely.”
criticalMedication management: “The provider had not put additional safety measures in place to ensure medicines being transcribed on the electronic system were accurate by being counter checked.”
criticalStaff competency: “Safe staff recruitment practices were not in place to reduce the risk of unsuitable staff from being employed.”
criticalGovernance: “Audits and management systems had not identified concerns we had found at this inspection in relation to recruitment, risk management and care plans, medicines and assessments of mental capacity.”
moderateRecord keeping: “Environmental risk assessment of people's home were carried out as part of the pre-assessment process, but were not consistently available on the electronic system.”
moderateConsent / capacity: “Care documentation did not always clearly evidence people's mental capacity particularly in relation to decision specific areas such as support with medicines administration.”
moderateIncident learning: “The registered manager had identified that some improvements were needed...monitoring of accidents and incident. However, auditing process had not been effective in identifying improvements required.”
Strengths
· People and relatives reported feeling safe and that staff supported them with their needs effectively.
· Staff had received safeguarding training and knew how to recognise and report abuse.
· DBS checks were completed for all staff.
· Staff had access to an on-call system to raise concerns outside office hours.
· The registered manager attended local forums to keep up to date with best practice.
Quality-Statement breakdown (9)
safe: Assessing risk, safety monitoring and management; Using medicines safelyRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
Farecare Gloucestershire Limited was rated Good across all five key questions at its January 2020 inspection, maintaining its previous Good rating from 2017. The service demonstrated safe, person-centred care with strong quality assurance systems, though a minor gap in obtaining full employment histories during recruitment was identified and immediately addressed.
Concerns (1)
minorRecord keeping: “a full employment history had not always been obtained following changes to recent recruitment documents”
Strengths
· Staff demonstrated clear awareness of safeguarding and whistleblowing procedures
· Electronic care planning and medicines records enabled regular audits and real-time updates
· Consistent staff teams organised by area, with advance notice of visit times provided to people
· A client and staff mentor role provided an effective point of contact for people, relatives and staff
· Complaints led to tangible improvements in care, including moving and handling assessments and medication support
Quality-Statement breakdown (21)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
Farecare Gloucestershire Limited was rated Good across all five key questions at its first CQC inspection in June 2017, demonstrating safe medication systems, person-centred care planning, well-supported staff and effective quality assurance. Minor concerns around the frequency of late visits and 12 medication errors over nine months were acknowledged by the registered manager and being actively addressed.
Concerns (2)
moderateMedication management: “There had been 12 medicine errors in the previous nine months. The medicine errors were all recorded and lessons learnt to stop them from happening again.”
minorMissed or late visits: “Three people we spoke with told us that staff were often later than planned but they would always turn up eventually and they would be told in advance if this was the case.”
Strengths
· Sufficient staffing levels maintained; director and registered manager regularly completed care shifts to keep service small and hands-on.
· Detailed, person-centred care plans reviewed and updated regularly to reflect changing needs.
· Staff received training tailored to individual learning styles, including safeguarding, MCA, dementia and end-of-life care.
· Regular supervisions every other month and annual appraisals completed for all staff.
· Robust complaints procedure with evidence of lessons learned shared with the whole staff team.
well-led:
Good
well-led: Working in partnership with othersGood
well-led: How the provider understands and acts on the duty of candour
Good
well-led: Working in partnership with othersGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
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: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Engaging and involving people using the service, the public and staff; continuous learning and improving careGood