Date of Assessment: 26 and 27 January 2026. Supreme Care Services Limited is a homecare agency providing personal care to adults with dementia, eating disorders, physical disabilities and sensory impairments. It provides personal care to people living in their own houses and flats in the community. Not everyone who used the service received personal care. At the time of our inspection there were 188 people using the service. We undertook this assessment due to the time since our last inspection. This was a comprehensive assessment and included all the quality statements across our five key questions. At our last assessment, we found the provider to be in breach of legal regulations relating to staffing. The previous breach of regulation 18 has been met by the provider. At this assessment, we found the provider to be in breach of 2 legal regulations in relation to safe care and treatment and good governance. The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. There was insufficient oversight of medicines management in line with current legislation and guidance. The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. There was no effective system of record keeping in place. Governance systems and audits were not effective in identifying or addressing areas for improvement. However, the provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider worked with people and staff to ensure there was continuity of care. The provider cared about and promoted the wellbeing of their staff.We have asked the provider for an action plan in response to the concerns found at this assessment.
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Supreme Care Services Limited remains rated Requires Improvement overall, with a breach of Regulation 18 identified due to persistent late care visits and ineffective staff deployment systems despite this issue being flagged at the previous inspection. Effective areas include safeguarding (no longer in breach of Regulation 13), medicines management, person-centred care, and staff training, while governance weaknesses around quality monitoring and care record accuracy continue to undermine the well-led domain.
Concerns (5)
criticalMissed or late visits: “we reviewed the call monitoring system and identified call visits were not taking place at the planned time.”
criticalStaffing levels: “The provider had failed to ensure there was a system in place for the effective deployment of staff. This was a breach of Regulation 18 (1).”
moderateGovernance: “The provider's systems did not always pick up some errors in people's care files and review notes.”
moderateRecord keeping: “1 person's review document had the wrong person's name recorded. Also, the mental capacity assessments for 2 people were not fully completed.”
minorCare planning: “there was a lack of guidance for staff to identify the signs of the person's health declining.”
Strengths
· Safeguarding systems improved since last inspection; all staff completed safeguarding training and provider no longer in breach of Regulation 13.
· Medicines managed safely with effective auditing system; MAR records correctly completed for all reviewed cases.
· Staff recruitment carried out safely including DBS checks, employment references and right-to-work verification.
· People reported feeling safe and well cared for, with kind, compassionate and person-centred staff.
· Effective infection prevention and control systems with adequate PPE supplies and management spot checks.
Quality-Statement breakdown (24)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentRequires improvement
safe: Assessing risk, safety monitoring and managementGood
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
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: 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: Supporting people to develop and maintain relationships to avoid social isolationGood
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: How the provider understands and acts on the duty of candourGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Continuous learning and improving careGood
well-led: Engaging and involving people using the service, the public and staffGood