Chenai Holistic Home Care Agency Ltd provides personal care to people in their own homes. CQC inspects only where personal care is provided, such as support with personal hygiene and eating, and considers any wider social care offered alongside this. At the time of the assessment, 53 people were using the service. The inspection took place between 30 March and 08 April 2026 and was announced. All quality statements under each of the five key questions were included. This assessment focused on whether the provider had met the requirements of a warning notice issued in relation to Regulation 17: Good Governance. The service had made significant improvements, and the conditions of the warning notice was met. At the previous inspection, breaches were identified in safe care and treatment, safeguarding, person centred care, dignity and respect, staffing and governance. The provider had made enough progress, and they were no longer in breach of any regulations. People’s needs were assessed before they began using the service. Staff worked effectively with external professionals to maintain continuity of care and received training about how to support people’s needs. Oversight of care visit monitoring had strengthened, and visits were monitored in real time. Risks were assessed, and staff had access to guidance to support safe care. People received the support they needed with medicines, which were reviewed regularly. Staff were positive about the improvements since the previous assessment and said they felt supported by the management team. The provider and senior leadership had developed systems to maintain oversight of the service and used lessons learned to drive ongoing improvement. This service has been in Special Measures since June 2025. The provider demonstrated improvements that have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
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Date of Assessment: 24 February to 17 March 2025. Chenai Holistic Home Care Agency is a domiciliary care agency providing care and support to people living in their own homes. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. At the time of our assessment the service supported 110 people with personal care. We found 6 breaches of the legal regulations in relation to safe care and treatment, safeguarding, person centred care, dignity and respect, staffing and governance at this assessment. Risk assessments were in place, however information within care plans were not always reflective of people’s needs and contained confusing information. We identified 3 incidents where the provider had not reported these to the appropriate safeguarding authorities or where necessary, CQC. Whilst records indicated no concerns with medicine administration, people and relatives raised some concerns about the way their medicines were administered. Care plans did not record people’s preferred method of receiving their medicines. There were not always enough suitably skilled staff to support people. People’s capacity to consent to care and support had not always been assessed in line with the Mental Capacity Act 2005 (MCA). People’s needs were assessed; however, the timing and duration of their care visits was not always provided in line with their assessed needs and preferences. People were not always treated with dignity or respect. Whilst most staff were positive about the support they received, we also received concerns in relation to their employment particularly around not being able to take their allocated leave and an expectation they had to cover shifts which resulted in their working week being extended. Governance systems were not effective in identifying or addressing areas for improvement. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded. This 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 the care they provide.
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Chenai Holistic Home Care Agency Ltd remains rated Requires Improvement overall following a focused inspection of Safe, Caring and Well-led domains, with a continued breach of Regulation 17 due to ineffective governance and oversight of care visit duration and staff deployment. Caring improved to Good, reflecting positive feedback about staff conduct, dignity, and involvement of people in their care.
Concerns (5)
criticalGovernance: “The provider had not ensured effective processes were in place to monitor the safety and quality of the service. This was a continued breach of Regulation 17”
criticalStaffing levels: “We found a significant number of their visits were half the agreed length of time. The provider was not able to evidence how they analysed this information”
moderateMissed or late visits: “Staff were not always staying for the agreed length of time. We also found issues with staff punctuality and the amount of time provided to people”
moderateCare planning: “Some risk assessments were not personalised and lacked clear guidance about how to keep people safe. For example, one person's epilepsy risk assessment lacked detail”
minorRecord keeping: “One member of staff did not have a full employment history recorded.”
Strengths
· People and relatives spoke positively about staff, describing them as kind, caring and respectful.
· Infection prevention and control had improved since the last inspection and was no longer in breach of Regulation 12.
· People were supported to take their medicines safely with medicines audits and spot checks in place.
· Staff understood safeguarding responsibilities and people told us they felt safe.
· The provider engaged regularly with people and relatives to gather feedback and check satisfaction.
Chenai Holistic Home Care Agency Ltd was rated Inadequate overall and placed in special measures, with continued breaches of regulations 12, 17 and 18 plus new breaches relating to safeguarding (13), person-centred care (9) and complaints (16). Inspectors found unsafe risk assessment, late/missed calls, falsified induction training, unreported safeguarding concerns and poor governance, although recruitment, infection control and partnership working were satisfactory.
Concerns (16)
criticalCare planning: “Risk assessments were not always robust. The service had failed to consistently assess individual risks or act on identified risks relating to the health and safety of people”
criticalMissed or late visits: “They do not come sometimes or they are very late. It happened frequently last weekend.”
criticalStaffing levels: “one person who required two staff had care provided by one staff member on two occasions because the second staff member failed to attend”
criticalStaff training: “we sat in on a staff induction session on 21 January 2020 and saw that the four attendees had been given the answers to the assessment questions in advance”
criticalStaff competency: “newly recruited staff were being adequately trained and their knowledge checked prior to providing care and support to people. This put people at risk”
criticalSafeguarding: “they had failed to record a further 22 safeguarding concerns and investigations raised by the local authority or notify the Care Quality Commission”
criticalGovernance: “Robust quality assurance processes were not in place to identify and address areas for improvement.”
criticalLeadership: “widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
criticalPerson-centred care: “Care plans were not always personalised or detailed and we found inconsistencies with some care plans.”
criticalComplaints handling: “a third complaint had taken three months to be resolved... the service had failed to respond appropriately and the quality of care had not improved.”
moderateCommunication with families: “There is a lack of co-ordination. We spend a lot of time chasing up, rotas are not issued and then someone unknown turns up. Communication is not good.”
moderateMedication management: “one MAR did not contain the month or the year and another did not contain the start date of the record... audits did not identify missing information regarding dates”
moderateIncident learning: “late or missed calls were not always thoroughly investigated to identify what went wrong so effective measures could be put in place”
moderateRecord keeping: “Complete and accurate records were not always maintained, including records of care provided and decisions taken in relation to people's care.”
moderateEnd-of-life care: “People's care plans did not contain evidence that the service explored people's preferences and choices in relation to end of life care and support.”
minorSupervision / appraisal: “some staff had concerns about the service old us they did not always feel supported by the management team”
Strengths
· Safe recruitment practices were followed including criminal record checks, employment history, references and right-to-work checks
· Infection prevention and control systems in place; PPE supplied and staff trained
· Staff knowledgeable about safeguarding and whistleblowing principles
· Mental Capacity Act assessments carried out and staff trained on MCA principles
· Service worked with district nurses, GPs and other agencies to support people's healthcare needs
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and managementInadequate
safe: Learning lessons when things go wrongInadequate
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentInadequate
safe: Systems and processes to safeguard people from the risk of abuseInadequate
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceInadequate
effective: Assessing people's needs and choices; supporting people to eat and drinkInadequate
Focused inspection found breaches of Regulation 12 (Safe care and treatment) for inadequate COVID-19 staff testing and Regulation 17 (Good governance) for weak oversight, late calls and unclear staff roles. Overall rating dropped from Good to Requires Improvement, with Safe deteriorating and Well-led remaining Requires Improvement.
Concerns (9)
criticalInfection control: “The provider was not following the government guidelines or their own policy and procedure in the testing of staff. Lateral Flow Tests (LFT) were being completed weekly instead of the recommended Polymerase Chain Reaction (PCR) tests.”
criticalGovernance: “Oversight and governance systems were not always in place to effectively monitor and assess the safety of the service.”
moderateMissed or late visits: “The times that they come - can I laugh at that? They're never on time.”
moderateStaffing levels: “Staff told us there was not enough staff, especially drivers, and they had calls added to their rota. This was causing them to be late for their calls.”
moderateLeadership: “The registered manager had not always provided clear lines of authority and effective communication about staff roles and responsibilities.”
moderateCommunication with families: “Communication could be better, between the company, people and their families and staff.”
moderateStaff training: “Staff completed online training to equip them with skills and knowledge but this did not always prepare them for their role.”
moderateIncident learning: “The provider did not have a contingency plan in place to support the service when things went wrong.”
minorRecord keeping: “Where staff supported people by applying topical creams, the areas for application were not always recorded on the person's body map.”
Strengths
· Staff had enough PPE and were using it effectively and safely
· Safeguarding policy and procedure in place; staff knew how to report concerns
· Risk assessments undertaken to guide staff on safe care
· People received their medicines as prescribed and MARs were audited
· Safe recruitment with DBS checks completed before staff started work
Quality-Statement breakdown (10)
safe: Preventing and controlling infectionNot rated
safe: Staffing and recruitmentNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Learning lessons when things go wrongNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empowering