Date of assessment: 3 December 2025 to 10 December 2025. Lalis Direct Care Ltd is a domiciliary care service. It provides personal care to people living in their own homes. At the time of our assessment, 11 people were receiving support with personal care. The service is registered to provide support for younger adults, dementia, learning disabilities, autism, mental health, older people, physical disabilities and sensory impairment. At the time of the assessment the service was providing care for only older people. The last rating for this service was good (published 21 February 2019). Following this assessment, the rating remains good. An assessment has been undertaken of a specialist service that is registered for use by autistic people or people with a learning disability. At the time of the assessment, the service was not used by anyone with a learning disability or an autistic person. 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. Medicines were managed safely and administered as prescribed. The provider completed investigations following incidents, accidents, safeguarding and complaints and actions for improvement were identified where necessary and implemented. Risks to people associated with their health and wellbeing were identified and risk management plans were developed. Staff felt supported by senior staff and felt able to raise any concerns with them. The provider completed a range of audits to monitor the quality of the care. The provider had a process to assess a person’s ability to make informed decisions about their care.
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Lalis Direct Care Ltd received an overall rating of Good at this January 2019 inspection, having successfully addressed previous breaches relating to complaints handling and governance. The single area of Requires Improvement relates to the Mental Capacity Act, where two mental capacity assessments were found to be incomplete or incorrectly signed, and the provider's own audits had failed to identify these shortfalls prior to inspection.
Concerns (4)
moderateConsent / capacity: “two mental capacity assessments to receive care from the provider were partially completed and signed by a family member when this was the responsibility for the staff to complete.”
moderateGovernance: “audits of people's records had not identified the short falls we had found about working in line with the MCA.”
moderateConsent / capacity: “the provider had not always ensured relatives had lasting Power of Attorney that gave them the right to make decisions on their family members behalf when they lacked capacity.”
minorRecord keeping: “some people's care plans, this information was limited to stating their religion and ethnicity only, and not their actual needs or how these should be met.”
Strengths
· Electronic call monitoring system linked to the local authority effectively flagged missed and late calls, resolving previous concerns about punctuality.
· Medicines administration records were completed appropriately with no errors or omissions; monthly MAR audits were conducted by senior staff.
· Staff received safeguarding adults and child protection training and could clearly articulate how to identify and report abuse.
· People and relatives spoke highly of staff, describing them as caring, kind, respectful and polite, with strong rapport built over time.
· Complaints handling was improved since the last inspection; all concerns raised were addressed promptly and to people's satisfaction.
Lalis Direct Care Ltd was rated Requires Improvement overall at its February 2016 inspection, with breaches of Regulations 12 and 17 due to absent specific risk management plans and ineffective quality audits that failed to identify these gaps. Caring and effective practice were rated Good, underpinned by positive feedback about staff and sound medicines management, but responsiveness and leadership were hampered by limited management visibility and inadequate involvement of people in care planning.
Concerns (7)
criticalCare planning: “Possible risks were identified but an assessment had not been carried out and guidance for care workers on how to reduce these risks had not been provided.”
criticalGovernance: “Audits had failed to highlight that there were no detailed plans in place for some risks identified during people's assessment.”
moderateRecord keeping: “There were no designated accident/incident forms completed which meant that it was difficult to audit the amount of episodes and what actions the provider had taken.”
moderatePerson-centred care: “Most people told us that they had not received a visit from the registered manager or the care coordinator, and had not taken part in the planning of their care.”
minorMissed or late visits: “Not great. They don't come at regular times, and don't always call when they are late.”
minorStaff training: “Staff told us that as part of the safeguarding training, they were informed of the principles of the MCA but did not receive in depth training.”
minorLeadership: “People we spoke with told us they did not know the registered manager and did not have any contact with them.”
Strengths
· People and relatives consistently praised carers as kind, caring and respectful, with many comments such as '10 out of 10'.
· Medicines administration records were fully completed with no gaps, and regular spot checks by care coordinators ensured safe medicines support.
· Sufficient staffing levels were maintained with contingency plans for absences and appropriate DBS and recruitment checks in place.
· Staff received induction, shadowing, one-to-one supervision, yearly appraisals and relevant training before supporting people unsupervised.
· Complaints were handled appropriately with evidence of swift resolution and follow-up action including additional staff training.
Quality-Statement breakdown (16)
safe: Risk assessment and risk managementRequires improvement
safe: SafeguardingGood
safe: Medicines managementGood
safe: Staffing and recruitmentGood
safe: Accident and incident recordingRequires improvement
Lalis Direct Care Ltd was rated Requires Improvement overall at its March 2017 inspection, with Safe rated Inadequate due to multiple breaches including failures in safeguarding, unsafe medicines management, and non-notification of incidents to CQC. Repeated breaches across care planning, consent, complaints handling, and governance indicated that improvements since the February 2016 inspection were insufficient.
Concerns (14)
criticalSafeguarding: “We were made aware of three specific incidents of abuse of people by their care workers. People told us they reported their concerns to the agency but the carers came back to intimidate the people.”
criticalMedication management: “The log book did not contain the list of medicines and the dosage that people had been prescribed to take.”
criticalMedication management: “If (medicines are) in blister pack we give and record in the book. If there is a lot we get confused and don't give it.”
criticalConsent / capacity: “The agency did not always work within the principles of the Mental Capacity Act 2005 (MCA) and there was a risk that decisions related to people's everyday care were not made in their best interest.”
criticalComplaints handling: “The agency did not view verbal complaints as formal complaints but as a misunderstanding about the service delivery. The agency did not have a central register of these conversations.”
criticalGovernance: “The agency had not informed the Commission about it, which they should have done. The provider had not displayed their most recent performance rating on their website.”
moderateCare planning: “People's care plans consisted of incomplete information in relation to their cultural and religious needs and preferences.”
moderatePerson-centred care: “Two people also told us that their care had been planned with the local authority but not the agency. People, or where appropriate, their legal representatives had not signed them.”
moderateGovernance: “The training matrix did not include those care workers who started their employment with the agency after June 2016.”
moderateRecord keeping: “Some information about risk to people's health and wellbeing was confusing and did not always match other risk assessment documents in people's files.”
moderateIncident learning: “The agency did not have a central accidents and incidents register which would allow it to analyse and identify any possible trends in the types of incidents and accidents recorded.”
moderateStaff competency: “Not all of them had a good understanding of the principles of safeguarding vulnerable adults from abuse.”
moderateMissed or late visits: “One person told us they frequently had to wait up to 45 minutes for carers to arrive. 'Sunday evening (they should be) at 6 o'clock, they had arrived at 6.45pm'.”
minorCultural competency: “One person's care plan stated care workers should respect the person's religion and culture, however, it did not say what the person's religion and culture were.”
Strengths
· Robust recruitment procedures with a three-stage application process ensured only suitable care workers were appointed.
· Care workers received regular training, supervision and yearly appraisals, with 13 of 22 staff completing or working towards NVQ Level 3.
· Agency worked closely with local authority and health professionals to support people's access to healthcare services.
· Care workers respected people's dignity and privacy when providing personal care.
· Rota system with contingency plans ensured call coverage and care workers knew their weekly assignments.
Quality-Statement breakdown (17)
safe: Safeguarding people from abuse and improper treatmentInadequate
safe: Safe management of medicinesInadequate
safe: Assessment and management of riskRequires improvement
safe: Staffing and recruitmentGood
effective: Mental Capacity Act and consentRequires improvement
effective: Nutritional needs recorded in care plansRequires improvement
effective: Staff training, supervision and appraisalGood
Lalis Direct Care Ltd showed improvement since its March 2017 inspection but retained an overall 'Requires Improvement' rating due to continuing breaches of Regulations 16 and 17, specifically persistent missed and late calls and ineffective complaints handling. Strengths included kind and consistent care staff, improved safeguarding, medicines management, person-centred care planning, and MCA compliance.
Concerns (5)
criticalGovernance: “The provider was failing to meet Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
moderateMissed or late visits: “There are frequent missed calls - I phoned the office - I'm also worried that if anything had happened in the day and they didn't turn up”
moderateComplaints handling: “I was told that they would look into the matter and things improved for a few days but then it slipped and I'm back on the phone again.”
minorRecord keeping: “There were no guidelines for staff to recognise any side effects from the medicines given.”
minorCare planning: “One person's risk assessment identified them as living with diabetes... no description of the possible concerns that might arise such as complications”
Strengths
· All people spoke very positively about care staff, describing them as caring, kind, respectful and polite
· Safeguarding concerns now referred appropriately and registered manager maintained an overview of concerns
· Medicines administration records completed appropriately without errors; staff demonstrated correct procedures
· Staff received regular supervision, induction, and training organised in line with the Care Certificate
· Care plans updated to be person centred, reflecting individual preferences, communication needs and promoting independence
Quality-Statement breakdown (17)
safe: Staffing deployment and missed/late callsRequires improvement
safe: Safe recruitment of staffGood
safe: Risk assessmentsGood
safe: Medicines administrationGood
safe: Infection controlGood
effective: Mental Capacity Act and consentGood
effective: Staff training and supervisionGood
effective: Nutrition and hydrationGood
caring: Dignity, respect and person-centred approach
Good
caring: Involvement in care decisionsGood
responsive: Care planning and reviewRequires improvement
responsive: Complaints handlingGood
responsive: Feedback and quality surveysGood
well-led: Governance and quality auditsRequires improvement
well-led: Leadership visibility and engagementRequires improvement
well-led: Staff support and team meetingsGood
caring: Kindness and compassion of care workersRequires improvement
caring: Dignity and privacyGood
caring: Seeking feedback from people and relativesGood
responsive: Involvement in care planningRequires improvement
responsive: Cultural and religious needs in care plansRequires improvement