Date of assessment: 13 and 21 January 2026. This was a planned assessment under the single assessment framework which is based on a set of quality statements. They are arranged under topic areas and describe what good care looks like. Ryedale Homecare is a domiciliary care service registered with the Care Quality Commission (CQC) to provide personal care to older people and younger adults including people living with dementia, learning disabilities or autistic spectrum disorder in their own homes. At the time of inspection, 13 people were receiving the regulated activity of personal care. The service remains rated as requires improvement. The provider was previously in breach of the legal regulation in relation to governance. Enough improvements were not found at this assessment, and the provider remained in breach of this regulation. Governance systems and audits were not effective and did not ensure safe or consistent care. Oversight remained limited in identifying and managing risks, and the provider had not implemented structured systems to make the required improvements. Although a new electronic care planning system had been introduced, it was not being used consistently, and records were not always complete or contemporaneous. Environmental risk assessments for people’s homes were not completed, and daily records were not routinely reviewed to identify emerging concerns. Some care plans lacked up‑to‑date risk assessments or clear guidance putting people at risk of harm. The provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were found at this assessment, and the provider was no longer in breach of this regulation. Staff files included appropriate recruitment checks, supervisions were completed, and medicines were managed safely. Staff competency checks had improved and were being expanded. Care plans for people with a learning disability and autistic people reflected individual needs. People told us staff treated them with dignity and respect, and staff understood their responsibilities under the Mental Capacity Act 2005. Safeguarding procedures were effective. We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. The provider was meeting the associated expectations. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.
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Ryedale Homecare received an overall rating of Requires Improvement following a focused inspection of Safe and Well-led domains, with continued breaches of Regulations 12 and 17 for failures in risk assessment, medication record-keeping, and governance. People and relatives reported positive experiences of kind, person-centred care, but systemic failures in auditing, incident recording, and care plan detail meant the service remained in breach for the second consecutive inspection.
Concerns (7)
criticalRecord keeping: “People's medical conditions were not fully assessed and records did not include the level of detail needed to ensure safe care.”
criticalMedication management: “Some people's medication on their care records did not match the MAR charts, some records were unclear, and signatures were missing.”
criticalGovernance: “Audits in place were not sufficient or robust enough to highlight all shortfalls identified on the inspection.”
criticalIncident learning: “Staff told us people had accidents however these had not been recorded, people's safety had not been managed and lessons had not been learnt.”
moderateCare planning: “More detail was needed in the care plans to ensure people's needs and preferences were fully understood and recorded.”
moderateConsent / capacity: “Best interest decisions had been made however these were not decision specific and the records did not evidence who was involved in the decision making.”
moderateMissed or late visits: “There was not a formalised system in place to ensure the monitoring of late or missed calls, the quality of the care or standard of care records.”
Strengths
· People told us they felt safe and praised the staff team; one relative said 'The staff have been tremendous'.
· Safe staffing numbers maintained; provider only accepted new packages if current staffing levels could accommodate them.
· Safe recruitment practices in place with robust induction processes including shadowing opportunities.
· Safeguarding training provided to staff including refresher training; staff understood their responsibilities.
· Staff wore PPE in line with current government guidance; infection prevention and control training refreshed annually.
Quality-Statement breakdown (9)
safe: Assessing risk, safety monitoring and management; Learning lessons when things went wrongRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
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: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
How the provider understands and acts on the duty of candour
Ryedale Homecare was rated Requires Improvement overall following a focused inspection of Safe and Well-Led, driven by concerns about medication record-keeping, inadequate care plan detail, and a lack of robust governance and audit systems. No harm was evidenced, but a breach of Regulation 17 (Good governance) was identified due to incomplete records and insufficient quality monitoring.
Concerns (6)
criticalMedication management: “Care plans, risk assessments and guidance for medicines prescribed when required did not contain enough information for staff to administer these consistently and safely.”
criticalGovernance: “The provider did not have a robust and transparent system of audits to evidence how they checked and made sure the service was safe.”
moderateCare planning: “Care plans and risk assessments did not always contain enough information to support staff to provide safe and consistent care.”
moderateRecord keeping: “Clear and complete records were not always in place relating to the management of the service or to support staff to provide safe and person-centred care.”
moderateStaff training: “The provider did not have a robust training plan or a clear way to monitor and make sure staff had the training they needed to provide safe high-quality care.”
minorSafeguarding: “The provider needed to update their safeguarding policy and procedure to ensure it contained detailed information about how safeguarding concerns would be managed.”
Strengths
· People praised staff as caring, flexible and exceptionally kind, with staff and management going above and beyond to meet needs.
· Staff were reliable and punctual, with people confirming staff contacted them if running late.
· PPE was readily available and used appropriately; staff followed good hand hygiene practices.
· The registered manager maintained open working relationships with healthcare professionals and responded proactively to concerns.
· People felt safe with the care provided and were confident management would respond to any issues.
Ryedale Homecare received an overall rating of Requires Improvement following a September 2016 inspection, with three regulatory breaches identified relating to unsafe recruitment practices, poor medication administration recording, and ineffective governance systems. Strengths were noted in the caring and responsive domains, with people and relatives consistently praising staff kindness, consistency, and person-centred approach.
Concerns (7)
criticalMedication management: “Staff did not appropriately record support provided for people to take prescribed medicines. Management checks were not robust enough to identify and address this.”
criticalRecord keeping: “The date, any allergies the person had and details of people's doctor was frequently not recorded on MARs.”
criticalGovernance: “Systems and processes in place to assess, monitor and drive improvement in the quality and safety of the service provided were not always effective.”
moderateStaff competency: “There was no evidence that robust medication competency checks were completed.”
moderateStaff training: “Four members of staff needed to update their medication management training, three needed to update safeguarding training.”
moderateConsent / capacity: “Staff did not complete or document mental capacity assessments or best interest decisions around consent to care.”
moderateSafeguarding: “Safeguarding training material had not been updated to reflect changes introduced by the Care Act 2014 and therefore was not reflective of current legislation.”
Strengths
· People who used the service consistently reported staff were kind, caring and maintained their dignity and privacy.
· Sufficient staffing levels in place with positive feedback about staff reliability and punctuality.
· Person-centred care plans were in place and regularly reviewed as people's needs changed.
· Staff demonstrated good understanding of safeguarding concerns and appropriate response procedures.
· Registered manager was approachable and responsive; people felt able to raise concerns.
Quality-Statement breakdown (13)
safe: Recruitment checksRequires improvement
safe: Medication administration and recordingRequires improvement
safe: Safeguarding systemsGood
safe: Risk assessment and staffing levelsGood
effective: Mental Capacity Act compliance and consent recordingRequires improvement
effective: Staff training and developmentRequires improvement
effective: Nutrition, hydration and healthcare accessGood
Ryedale Homecare improved from 'Requires Improvement' to 'Good' overall following a previous inspection that identified breaches in medicines records, recruitment checks and governance. All five key questions were rated Good, with the registered manager demonstrating sustained improvements in quality assurance, person-centred care and staff support, though minor gaps remained in policy dating, audit recording and regularity of staff meetings.
Concerns (3)
minorRecord keeping: “we identified that the policy was not dated so we could not be sure the policy had been updated to reflect changes in current best practice”
minorGovernance: “the action taken had not been clearly recorded. We discussed this with the manager who told us they would ensure all audits included a section to record actions taken”
minorSupervision / appraisal: “Regular staff meetings had not always taken place but plans were in place to improve this... these had previously only been planned to take place once a year”
Strengths
· Robust recruitment procedures implemented with full employment histories, DBS checks, references and recorded interviews
· Improved medicines administration with monthly MAR audits and competency assessments for staff
· Consistent small staff team enabling strong person-centred relationships and knowledge of individual preferences
· Close working relationships with external professionals including GPs, district nurses and social workers
· Person-centred care plans including life stories, individual preferences and daily care needs
Quality-Statement breakdown (18)
safe: SafeguardingGood
safe: RecruitmentGood
safe: Medicines managementGood
safe: Risk assessmentGood
safe: Staffing levelsGood
effective: Staff training and inductionGood
effective: Supervision and competency assessmentGood
effective: Mental Capacity Act / consentGood
well-led:
Good
well-led: Engaging and involving people using the service, the public and staff; Working in partnership with othersGood
caring: Choice and controlGood
responsive: Person-centred care planningGood
responsive: Complaints handlingGood
well-led: Quality assurance and governance systemsRequires improvement