Date of assessment: 08 September 2025 to 13 October 2025. We announced the assessment on 08 September 2025 and carried out visits to the office on 09, 10 and 11 September 2025. The service had a registered manager who is responsible for supervising the management of the regulated activity provided. The service is a domiciliary care agency and provides personal care to people living in their own homes. Not everyone was receiving personal care. CQC only inspects where people are receiving the regulated activity personal care. This is help with tasks related to personal hygiene and eating. Where they do, we consider any wider social care provided. At the time of this assessment 100 people were receiving support with personal care. The assessment was prompted following a review of information we held about the service and to assess where improvements had been made based upon the previous assessment when we identified 8 breaches of regulations. These were in relation to person centred care, gaining consent, safe care and treatment, safeguarding, receiving and acting on complaints, good governance, staffing and fit and proper persons employed. At this assessment we found not enough improvement had been made and the provider remained in breach of 7 of the 8 regulations. They had improved their management of receiving and acting on complaints. Although there were plans to support people, many risks were not managed, and staff lacked clear guidance about people’s known health conditions. The information and instructions given to staff needed improvement so they could manage risks properly and support people safely. The provider’s audits of the service failed to identify the concerns we found during this assessment. We could not be assured there were enough staff with the right skills, qualifications and experience to support people safely. The provider failed to ensure all staff received suitable training, competency assessments and regular supervisions to maintain high-quality care. Recruitment practices were not robust, including the appropriate checks prior to staff commencing employment and working with vulnerable people and children. Processes were not robust for people who required support with their medicines. Systems to monitor people’s calls were not effective leading to late, short and missed calls. People were not receiving consistent person-centred care that met their needs. We 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. We found they failed to meet these requirements. In instances where CQC has 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 remains 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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Living Glory Social Care, a Birmingham domiciliary care agency supporting 228 people, was rated Inadequate overall following a January 2024 inspection, with warning notices issued for breaches of Regulations 12, 13, 17 and 18, and the service placed in special measures. Widespread failures were identified across safeguarding, medicines management, missed and late visits, care planning, consent, governance and recruitment, representing a significant deterioration from its previous Good rating in 2019.
Concerns (19)
criticalSafeguarding: “multiple safeguarding concerns had not been identified, reported, or actioned robustly. This included people at risk of inappropriate restraint, going missing and police incidents.”
criticalMedication management: “Care plans and risk assessments contained conflicting, inconsistent or no information, to guide staff on the level of medication support people needed. This was unsafe.”
criticalMissed or late visits: “Records showed some people's care calls lasted for less than half of the required time.”
criticalCare planning: “Risk assessments were either not in place or were not sufficiently detailed to help staff provide safe care.”
criticalGovernance: “Only 90 of the people using the service had been added to the provider's electronic care planning system which meant the outstanding people were not having their call times monitored.”
criticalStaffing levels: “A single staff member sometimes attended calls for people who required 2 staff to support them safely.”
criticalConsent / capacity: “We had concerns in relation to the registered manager's understanding and application of the MCA. The required principles of the MCA were not consistently applied.”
criticalLeadership: “The provider told us they could now see, following our inspection, that they had grown too quickly without the correct systems and processes imbedded.”
moderateStaff competency: “Competency checks of staff skills were not completed. This meant the provider could not be assured staff were safely and effectively applying their learning.”
moderateSupervision / appraisal: “Systems in place to ensure staff received regular and supportive supervisions, were not robust. We nor the provider could be assured these had been regularly completed for all staff.”
moderateIncident learning: “Due to the lack of analysis of feedback, complaints, compliments, daily records and incidents and accidents, the provider failed to robustly identify, and cascade lessons learnt.”
moderateComplaints handling: “There had been no complaints recorded since 2015 although we are aware complaints had been raised with the provider.”
moderatePerson-centred care: “Staff do not help to promote [relative's] independence and help them to achieve goals and aspirations and they get bored.”
moderateRecord keeping: “The provider had failed to provide us with the full and correct details of all people supported by them as their systems and processes to track people using the service were not robust.”
moderateCultural competency: “A staff member had not respected their cultural beliefs, which had resulted in the family raising safeguarding concerns.”
moderateStaff training: “Some staff told us they had not received specific training for people's known health conditions or how to respond when people exhibited distress.”
moderateCommunication with families: “Staff simply do not speak to them and do not appear to understand that the person is able to understand them although they can't communicate with them.”
minorInfection control: “The provider could not be assured all staff were following safe practices and were adhering to the correct use and safe disposal of personal protective equipment (PPE).”
minorEnd-of-life care: “The provider told us they had yet to commence work developing people's care plans to ensure people's preferences and choices for their end of life care were acted on.”
Strengths
· All staff files reviewed had a Disclosure and Barring Service (DBS) check completed prior to staff commencing employment.
· Staff told us they had received an induction and had the opportunity to shadow other staff members prior to supporting people on their own.
· Some people provided positive feedback: 'The care is second to none. Carer [Name] comes all the time and treats [relative] like she is her own [relative].'
· The provider employed staff from different cultural and religious backgrounds with the intention to allocate staff from the same culture or who spoke the same language as the person.
· Many people told us they were able to speak to someone out of hours if they needed to contact them.
Quality-Statement breakdown (23)
safe: Systems and processes to safeguard people from the risk of abuse and avoidable harmInadequate
safe: Assessing risk, safety monitoring and managementInadequate
safe: Staffing and recruitmentInadequate
safe: Using medicines safelyInadequate
safe: Learning lessons when things go wrongInadequate
safe: Preventing and controlling infectionRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Staff support: induction, training, skills and experience