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Date of assessment: 25 June 2025 to 17 July 2025, including site visits on 25 June 2025 and 2 July 2025. Allfor Care Croydon is a care at home service providing personal care to 289 adults of all ages living with dementia, mental health conditions, learning and/or physical disabilities. This assessment was conducted in response to whistleblowing, safeguarding concerns and complaints about missed or late calls. Governance failures meant the registered manager and staff lacked the specific knowledge needed to understand and address the serious, unacknowledged pattern of recurring late and missed care calls. The provider continuously missed opportunities to identify recurring themes, preventing necessary improvements that would have addressed underlying operational flaws. The provider did not cultivate a safe culture for learning where lessons learnt were routinely integrated after adverse events. Systemic failures meant not all risks to people’s health and welfare were identified. Where risks were noted, especially concerning medical conditions such as epilepsy, asthma, or the use of blood thinners, management plans to actively mitigate the risk of harm were often missing. This gap between identifying and managing serious risks meant the potential for people to be harmed was significant. The provider did not consistently conduct appropriate assessments of people’s care and support needs, which meant staff could not provide effective, person-centred tailored care. Without these vital assessments, staff lacked the information needed to manage people’s health and welfare and identify deterioration. In addition, staff did not always uphold the principles of the Mental Capacity Act 2005 (MCA), specifically by failing to apply the least restrictive alternatives. They also lacked a clear understanding that valid consent must always be decision specific. The provider failed to ensure staff competence across various job roles, particularly in conducting accurate needs assessments, designing genuinely person-centred care plans, and carrying out quality assurance audits. The service's training matrices documented that staff had completed all mandatory and specialist training. However, there were no records to demonstrate how the service monitored or checked training received was applied and embedded in daily practice. The service had unsafe recruitment practices, failing to conduct thorough checks on new employees' work histories, obtain explanations for employment gaps, and ensure the accuracy of documented information. Furthermore, medicine administration practices were not always safe because the provider failed to ensure staff followed its medicine policy and current best practice. 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 failed to demonstrate a good working knowledge or effective implementation of the principles set out in the 'Right Support, Right Care and Right Culture' guidance. We found 12 breaches in relation to person-centred care, dignity and respect, need for consent, safe care and treatment, safeguarding service users from abuse and improper treatment, receiving and acting on complaints, good governance, staffing, fit and proper persons employed, duty of candour, statement of purpose and notifications. This service is being placed in special measures. The purpose of special measures is to ensure 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 care they provide. 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.
npm run etl:reports -- --location 1-9322505965.Allfor Care Croydon received a Good rating across all five key questions at its first CQC inspection in July 2021, with 207 people receiving personal care safely and in a person-centred manner. The service demonstrated strong governance, proactive risk management, cultural competency, and effective partnership working with no failure themes identified.