We carried out this inspection on 19 November 2025. This was an assessment covering all 5 key questions. This assessment was to follow up on the findings from our previous inspection. The service is a care at home service providing support to people living in their own homes. At our last inspection, we found that the provider was in breach of the legal regulations in relation to safe care and treatment, safeguarding service users from abuse and improper treatment and governance. At this inspection, we found some improvements had been. However, the provider remained in breach of regulation in relation to governance. Governance systems had failed to identify concerns with medicine protocols, the notification of safeguarding incidents to the CQC and some omissions in people’s care plans. However, there were enough safely recruited staff to support people safely. Staff had received training and were supported in their role. People were protected and kept safe as staff understood their roles and managed risks. People were supported by kind and caring staff and they treated people with respect and dignity. There were systems in place to support people and staff which ensured equality, diversity and human rights. There were processes in place for people to speak up if they had any concerns. This service is registered for use by autistic people or people with a learning disability. At the time of the assessment, no people with a learning disability or autism were in receipt of personal care. 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 and we found that the provider met the required standards for delivering this care. We have asked the provider for an action plan in response to the concerns identified at this inspection.
PDF cached but not yet analysed by Claude; set ANTHROPIC_API_KEY and re-run npm run etl:reports -- --location 1-2950714170.
Sinai Care Solutions Limited was rated Requires Improvement across all five key questions at its first inspection in June 2019, with breaches of Regulations 12, 13, 17 and 18 identified relating to unsafe medicines management, unreported safeguarding incidents, and ineffective governance systems. While individual staff were described as kind and caring by people using the service, systemic failures in oversight, care planning accuracy and Mental Capacity Act compliance presented significant risks to people's safety and wellbeing.
Concerns (10)
criticalMedication management: “Medicine management was not consistently safe. MAR contained gaps and some records were not accurate and did not reflect the person's current prescribed medicines.”
criticalSafeguarding: “Two incidents, including unexplained bruising, which had not been followed up by the provider or reported to the local authority.”
criticalSafeguarding: “One staff member told us they would tell the adult that any conversation about safeguarding was 'between the two of us' and would not report safeguarding concerns unless the adult agreed.”
criticalGovernance: “Systems in place to audit the service had failed to identify and address medicine errors. There were no auditing systems in place to identify trends and reduce risk.”
criticalRecord keeping: “People's hospital grab sheets omitted important information such as one person's medication allergies and another person's health condition.”
moderateCare planning: “Care plans did not always contain personalised information such as people's hobbies and religion. There was no effective system to ensure care plans provided sufficient guidance.”
moderateConsent / capacity: “Consent forms had been signed by a family member when they did not have the legal authority to do so. Decision specific capacity assessments or best interests decisions not recorded.”
moderateIncident learning: “Although action was taken, we identified ongoing concerns and further learning and action was required following a complaint with regards to medication administration.”
moderatePerson-centred care: “Personalised support was not always given. A relative told us, 'I have to stay on top of things, it's the little things.'”
moderateStaff competency: “Staff received training from an external training provider, however we found that staff did not always put their training into practice, such as regarding medication.”
Strengths
· People and relatives consistently reported feeling safe and expressed trust in individual carers.
· Staff demonstrated understanding of people's care needs and respected diversity and religious beliefs.
· People were supported by regular staff, fostering positive relationships and continuity of care.
· People's dignity, privacy and independence were respected and promoted by staff.
· The service supported people to access healthcare services and other agencies in a timely manner.
Quality-Statement breakdown (22)
safe: Using medicines safely; Assessing risk, safety monitoring and managementRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Supporting people to live healthier lives, access healthcare services and supportGood
caring: Ensuring people are well treated and supported; respecting equality and diversityRequires improvement
caring: Respecting and promoting people's privacy, dignity and independenceGood
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 needsGood
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
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: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Working in partnership with othersRequires improvement
well-led: Continuous learning and improving careRequires improvement