Date of assessment 11 December 2025 to 6 January 2026. Profad Care Agency Limited is a Domiciliary Care Agency (DCA) registered to provide personal care. People were supported with their personal care needs to enable them to live in their own homes and promote their independence. At the time of this assessment 21 people were using the service. The service had a manager registered with the Care Quality Commission. The registered manger and provider are legally responsible for the quality and safety of the care provided. The assessment was carried out by one inspector and one expert by experience. We spoke with eight people and their relatives. At our last inspection the service was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Improvements were found during this assessment, and the provider was no longer in breach of this regulation. At our last inspection the service was in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Although some improvements were found at this assessment, the provider remains in breach of this regulation. There were systems and processes in place to ensure the safety and quality of the service. The provider had oversight of the service to help to ensure improvement in people’s care and risks to people were mitigated. We were not assured that people consistently received their medicines as prescribed; however, the registered manager took steps to amend this during this assessment Safe recruitment practices were in place, however this could be further improved, for example ensuring all referee email details had been verified. Systems were in place to protect people from the risk of abuse. Staff understood how to keep people safe and how to report concerns. The registered manager promoted a positive culture that supported choice and independence. People’s social, cultural and religious needs were met. The management team worked in partnership with other professionals to ensure good outcomes for people. Staff received regular supervision and appraisals and felt supported by the manager. People and their relatives were invited to give feedback on care and received regular reviews. The last rating for this service was requires improvement (published 13 February 2023). At this assessment we found the provider remained in breach of regulation 17, although improvements had been made, the service remains requires improvement.
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Profad Care Agency Limited remains rated Requires Improvement overall and is in special measures, with continued breaches of Regulations 12 and 17 due to unsafe medicines management, absent quality assurance audits for 12 months, out-of-date staff training, and unsafe recruitment practices. The service has been rated Requires Improvement for three consecutive inspections and the Well-led domain remains Inadequate, placing people at ongoing risk of harm.
Concerns (8)
criticalMedication management: “Medicine for 1 person had not been transcribed correctly on the Medication Administration Record (MAR) chart. There was inconsistent information about the prescribed dosage.”
criticalGovernance: “There had been no quality assurance audits undertaken by the provider or their representative for 12 months.”
criticalStaff training: “Not all staff who were administering medicines and supporting people with moving and handling tasks had received up to date training. This put people at risk of unsafe care.”
criticalRecord keeping: “Medicine that has been prescribed as a short course, was incorrectly recorded on the 'as and when required' (PRN) section of the MAR chart.”
criticalLeadership: “At the time of our inspection there was not a registered manager in post. A new manager had been in post for 2 months and had submitted an application to register.”
criticalSafeguarding: “The providers systems and processes had not identified a lack of satisfactory evidence of staff conduct in previous employment concerned with the provision of services relating to health or social care.”
moderateStaff competency: “People were supported by staff who had not received up to date training or had their competencies assessed.”
moderateMissed or late visits: “We received feedback from people and their relatives that staff left some care visits early and logged out of the electronic system away from people's home.”
Strengths
· Staff were knowledgeable in safeguarding people and understood the signs of abuse and how to raise concerns inside and outside of the organisation.
· Individualised risk assessments were in place with clearly recorded guidance in care plans to enable staff to mitigate risks.
· The provider was using PPE effectively and safely and infection prevention and control policy was up to date.
· Accidents and incidents were recorded and monitored for trends and patterns to prevent future incidents.
· Staff received regular supervisions and appraisals and felt well supported by the new manager.
Quality-Statement breakdown (9)
safe: Using medicines safely; Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsInadequate
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staff
Profad Care Agency Limited received an overall rating of Requires Improvement following a focused inspection in May 2021, with the well-led domain deteriorating to Inadequate due to continued and unresolved breaches of Regulation 12 (Safe Care and Treatment) and Regulation 17 (Good Governance) first identified at the previous inspection. Critical failures included incomplete and inaccurate care plans, medication administration record gaps, absence of incident monitoring systems, two GDPR data breaches, and ineffective complaints handling, resulting in Warning Notices being issued.
Concerns (8)
criticalCare planning: “There were whole sections of the care plan left blank for multiple people and the details of a person's living arrangements and environment were not always completed.”
criticalMedication management: “Medicine Administration Records (MAR) contained missed signatures...prescribed creams were not included on the MAR to evidence these had been applied as required.”
criticalGovernance: “Audits had not been completed in line with the providers procedures...all the shortfalls found during the inspection had not been identified by the provider.”
criticalRecord keeping: “Staff had not consistently recorded repositioning tasks, skin integrity checks and when creams were applied to people's skin. We found multiple gaps in these records.”
criticalLeadership: “The provider had not kept people's personal information safe. There had been two occasions of a personal data breach under General Data Protection Regulation (GDPR).”
moderateIncident learning: “There was no system in place to monitor accidents and incidents to identify possible trends and patterns.”
moderateMissed or late visits: “[Person's] first morning call should be at 9.30am and the carer is not turning up until 11am.”
moderateComplaints handling: “Not all complaints received had been logged as a complaint therefore, they had not been investigated or responded to appropriately.”
Strengths
· Staff were recruited safely with pre-employment checks including DBS checks and references completed.
· Staff had received safeguarding training and understood how to recognise and report abuse.
· Infection control policy was in place; staff had access to regular COVID-19 testing and PPE training.
· People were involved in the planning of their care and had signed their care plans where able.
· The service gained feedback from people using the service to identify improvements.
Quality-Statement breakdown (10)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
well-led: Promoting a positive culture; managers and staff clear about roles and governanceInadequate
well-led: Duty of candour and complaints handlingInadequate
Profad Care Agency Limited, a newly registered domiciliary care agency in Rushden, was rated Requires Improvement overall at its first inspection in September 2020, with breaches of Regulation 17 (Good Governance) identified due to ineffective oversight, incomplete risk assessments, absent PRN medication protocols, and conflicting MCA documentation. The service demonstrated strengths in its caring approach, safeguarding awareness, infection control, staff training, and responsiveness to complaints, with the registered manager acting promptly to address identified issues.
Concerns (6)
criticalCare planning: “People's risks were not always appropriately identified and assessed. Staff were not always provided with clear guidance to manage people's risks.”
criticalMedication management: “When people required medicines as and when (PRN), the correct PRN protocols were not in place and there was no guidance to inform staff when to administer these medicines.”
criticalConsent / capacity: “Information within MCA assessments and care plans was often conflicting and we did not see evidence of best interest decision processes having been followed.”
criticalGovernance: “There was a lack of oversight and systems to monitor the service were not effective. Audits had not identified the issues we found during inspection.”
moderateRecord keeping: “Incorrect personal information contained within risk assessments was duplicated across several different people's care plans and this had not been identified during audits.”
minorEnd-of-life care: “Care plans did not include information on end of life care and support.”
Strengths
· Staff were trained in safeguarding procedures and knew how to protect people from harm and abuse
· Sufficient staffing levels with consistent staff who knew people well
· Infection prevention and control was well managed with appropriate PPE available and used
· Robust induction policy including Care Certificate and regular supervision and training
· Staff and management team described as kind, caring and compassionate by people and relatives
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law
Requires improvement
well-led: Working in partnership with others; Promoting a positive person-centred cultureGood
well-led: Engaging and involving people; continuous learning and improving careInadequate
well-led: Working in partnership with othersGood
Good
effective: Staff support: induction, training, skills and experienceGood
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 controlGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
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