Date of assessment: 20 January 2026 to 20 February 2026. Sentricare Care is a homecare service providing the regulated activities of personal care to people living in their own homes. The Care Quality Commission (CQC) only inspects where people receive personal care. Personal care includes help with tasks related to personal hygiene and eating. Where this support is provided, we also consider any wider social care delivered as part of the service. At the time of our inspection there were 26 people receiving personal care supported by the service. We carried out this inspection, due to the length of time since the last inspection, and to follow up on previous breaches.” We completed the inspection under key questions Safe, Effective, Caring, Responsive and Well-Led. The provider was previously in breach of the legal regulations in relation to person centred care, dignity and respect, need for consent, safeguarding service users from abuse and improper treatment, receiving and acting on complaints, staffing, fit and proper persons employed, duty of candour. Improvements were found at this assessment, and the provider was no longer in breach of these regulations. The overall rating at this assessment is requires improvement. We identified 2 continued breaches of the legal regulations in relation to safe care and treatment and good governance. Auditing processes were not always effective in identifying shortfalls. Medication administration records (MAR) records did not always accurately reflect prescribed medicines, administration instructions, and did not always correspond with blister packs or medication pen pictures. There was limited evidence of meaningful involvement of people using the service, or their relatives in governance or quality improvement processes. Governance processes did not identify inconsistencies in care and medicines records. There was a registered manager in post. The provider worked with local authorities and district nursing services. They also supported people who had paid for their care privately. People were treated with kindness and compassion. Staff protected people’s privacy and dignity. Staff treated people as individuals and supported their preferences. People had choice in their care and were encouraged to maintain relationships with family and friends. The provider supported staff wellbeing. The provider supported a small number of people with a learning disability or autistic people. 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. Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. People and staff with protected characteristics felt supported. Staff understood their roles and responsibilities. We found the provider and registered manager responsive to our feedback throughout the course of the inspection. We have asked the provider for an action plan in response to the concerns found at this assessment. Recruitment processes were robust, with staff having completed Disclosure and Barring Service (DBS) checks, employment history verification, and induction training. Staff demonstrated a clear understanding of their safeguarding responsibilities. This service has been in Special Measures since 04/12/2024. The provider demonstrated improvements that have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures. The provider was previously in breach of the legal regulations in relation to person centred care, dignity and respect, need for consent, safeguarding service users from abuse and improper treatment, receiving and acting on complaints, staffing, fit and proper persons employed, duty of candour. Improvements were found at this assessment, and the provider was no longer in breach of these regulations.
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Sentricare Birmingham received an Inadequate rating across all five key questions following a July 2022 inspection of this 282-person domiciliary care service, with conditions imposed on registration across nine regulatory breaches. Pervasive failures in missed, late and short care calls, unsafe medication management, ineffective safeguarding, poor governance and a lack of person-centred care placed people at serious risk of harm.
Concerns (18)
criticalMissed or late visits — “For one person during a month, 75 of the 264 scheduled calls which took place were 50% or below the commissioned 30 minutes length of call.”
criticalStaffing levels — “There was not enough staff employed and effectively deployed to meet people's needs. Staff rotas did not always allow travel time between calls or more than one call was scheduled at the same time.”
criticalMedication management — “Some people were not given their medicines at the time they had been prescribed... medicine for the control of diabetes, heart conditions and pain relief which should be administered at specific times.”
criticalSafeguarding — “Three people had reported to the provider thefts of their personal items... the provider had failed to put into place or consider any steps to mitigate the risk of this happening again.”
criticalCare planning — “Care plans were not fully personalised, and information contained within them had not been reviewed and updated to reflect people's current support needs.”
criticalGovernance — “Although there was a system to audit aspects of the service, we found these had failed to identify people were not supported safely in a way they chose.”
criticalStaff training — “Staff had not received practical moving and handling training or had their competencies assessed, to ensure safe practices were adhered to.”
criticalComplaints handling — “One person told us they had called one weekend over 150 times with no answer. Others told us they had given up making complaints as no-one called them back.”
criticalRecord keeping — “Staff could log in to a call when they were not in attendance. This meant there were no assurances staff attended the calls, on time or for the correct length of time.”
criticalConsent / capacity — “The provider did not ensure people's consent was gained prior to support being provided. This was a breach of Regulation 11.”
criticalPerson-centred care — “All 81 people and relatives we spoke with told us they had not been involved in care reviews or care planning meetings.”
criticalIncident learning — “Incidents had not been consistently recorded or acted on... no record that staff discussions had taken place to consider the management of incidents.”
moderateStaff competency — “Spot checks and competency assessments were not carried out to ensure staff were applying their skills and knowledge in the right way.”
moderateSupervision / appraisal — “Some staff told us they received supervision and attended meetings, but others told us they did not, records also demonstrated this.”
moderateInfection control — “Staff were not adhering to current guidance on the practise of lateral flow testing... the provider could not be assured staff were not attending calls when they were COVID-19 positive.”
moderateCommunication with families — “People were not consistently communicated with in their preferred language. Some staff members spoke over them in their own language and did not communicate with them.”
moderateLeadership — “The registered manager was not in the service on a full time basis... Lack of management oversight had contributed to the shortfalls identified.”
moderateCultural competency — “Although some staff members understanding and communication in English was limited the training provided on-line was presented in English and alternative formats had not been provided.”
Strengths
· Staff told us they had received an induction when starting work and had the opportunity to shadow other staff.
· Staff we spoke with understood people's support needs and told us how they supported people to do as much for themselves as they were able.
· PPE stocks were available in the office for staff to collect when needed.
· Staff knew what to do if they had concerns about a person's health or if there was a medical emergency.
· The management team were receptive to inspection feedback and shared details of actions being taken to address concerns.
Quality-Statement breakdown (20)
safe: Assessing risk, safety monitoring and managementInadequate
safe: Staffing and recruitmentInadequate
safe: Using medicines safelyInadequate
safe: Preventing and controlling infectionInadequate
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongInadequate
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawInadequate
effective: Staff support: induction, training, skills and experienceInadequate
effective: Ensuring consent to care and treatment in line with law and guidance
Sentricare Birmingham received an Inadequate rating across all five key questions at this follow-up inspection (August 2023), remaining in special measures with conditions imposed on registration after failing to make required improvements since the previous Inadequate rating in March 2023. Widespread and continued breaches of ten regulations were identified, including unsafe medicines management, chronic missed and late calls, inadequate safeguarding, poor governance, non-compliance with the Mental Capacity Act, and a leadership culture described by staff and people as bullying and unapproachable.
Concerns (18)
criticalMedication management — “Care plans and risk assessments contained conflicting or inconsistent information to guide staff on the level of medication support people needed. This was unsafe.”
criticalMissed or late visits — “For 1 staff member, the provider had unsafely scheduled 36 care calls between 05.50 and 23.00hrs...calls were scheduled to overlap.”
criticalStaffing levels — “Not enough staff members were deployed by the provider to support people...travel time and the full allocation of time staff needed to provide care was not factored into their rotas.”
criticalSafeguarding — “Multiple safeguarding concerns had not been identified, reported, or actioned robustly. This included short and late care calls which resulted in people not receiving the correct level of support.”
criticalGovernance — “The providers governance systems and oversight of the service provided remained inadequate...call cramming and the working time directive not being applied.”
criticalCare planning — “Care plans and risk assessments continued to lack robust and clear guidance, with incorrect or conflicting information. Risk assessments continued to fail to direct staff on recognising symptoms.”
criticalConsent / capacity — “The provider was not compliant with the MCA...mental capacity assessments were not decision specific. For example, 'they do not have full capacity because they have slurred speech'.”
criticalStaff competency — “Competency checks of staff skills were not always completed. Some staff members understanding and communication of English was limited; training continued to be predominantly online in English.”
criticalComplaints handling — “Complaints were not consistently recorded and the actions that had been taken to prevent similar occurrences were not recorded. 'They never get back to you. They just don't ever sort out complaints.'”
criticalRecord keeping — “Staff had recorded they had 'administered' 1 person's medicines which conflicted with the record which also documented 'no one had opened the door'. Records were confusing and inaccurate.”
criticalIncident learning — “Incidents were not consistently recorded or acted on...people were at risk from potential further incidents happening, as concerns were not always identified and appropriate actions had not always been taken.”
criticalPerson-centred care — “Care was not always person centred and people were not empowered to influence their care and support. People did not consistently receive care that met their needs and preferences.”
criticalLeadership — “Some staff and people referred to the registered manager as a 'bully'. Some staff told us they were fearful of approaching the registered manager about their rota as they were threatened with having their hours reduced.”
moderateInfection control — “'My regular carers wear masks and gloves, the weekend ones don't. I have to chase them out if they come in and are coughing, I am very vulnerable.'”
moderateCommunication with families — “'If a call has been cancelled or carers are not on time the communication to inform the client is not good'...language barriers with new carers sometimes.”
moderateSupervision / appraisal — “The providers records demonstrated staff competency checks, to confirm staff were working in line with their expectations had not routinely been completed for all staff.”
moderateStaff training — “Some staff members told us they found the monthly training 'repetitive' and 'not informative'...some staff were unable to tell us what they had learnt from certain training.”
moderateCultural competency — “Whilst it was the provider's intention to allocate staff from the same culture or who spoke the same language, this did not always happen...people remained unable to always effectively communicate with staff.”
Strengths
· Staff members joining the service from overseas had evidence of police checks from their country of origin.
· DBS check compliance had improved since the last inspection; at least 2 staff previously lacking pre-employment DBS checks had been addressed.
· Some people and relatives provided positive feedback about individual carers going the extra mile and being kind and caring.
· Records demonstrated the provider had gained feedback from some people and relatives via questionnaires.
· Staff told us they knew what to do if they had concerns about a person's health or if there was a medical emergency.
Quality-Statement breakdown (22)
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongInadequate
safe: Using medicines safelyInadequate
safe: Assessing risk, safety monitoring and managementInadequate
safe: Preventing and controlling infectionInadequate
safe: Staffing and recruitmentInadequate
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawInadequate
effective: Staff support: induction, training, skills and experienceInadequate
effective: Ensuring consent to care and treatment in line with law and guidance
Sentricare Birmingham received an Inadequate rating across all five key questions following inspections in December 2022 and January 2023, with the provider remaining in special measures and breaching ten regulations including safeguarding, medicines management, staffing, governance, and duty of candour. The provider systematically concealed the true number of people using the service (initially declaring 12, actual figure at least 92), failed to implement improvements since the previous Inadequate rating, and had enforcement conditions imposed on its registration.
Concerns (17)
criticalMedication management — “medicines were not always given as prescribed...calls taking place at much later times than scheduled or staff simply not giving them or giving at the wrong time”
criticalMissed or late visits — “Records showed that some people's care calls still continued to last for less than half of the required time...some staff were recording they were in attendance of two calls at the same time”
criticalSafeguarding — “multiple examples of safeguarding concerns which had not been either identified, reported or actioned robustly...including the impact of people being exposed to missed calls”
criticalGovernance — “provider told us they had not had good oversight of the service as they had delegated this task to a manager who had recently resigned”
criticalStaffing levels — “people who required two staff to support them often only one member of staff attended their call...staff allocated rotas continued to not always have travel time between calls”
criticalRecord keeping — “electronic records often had 'No outcome' for medicines as staff had not completed the records...inaccurate and unclear information in people's care plans”
criticalCare planning — “Care plans and risk assessments did not provide staff with information on how to respond to such expressions of distress, how to de-escalate”
criticalComplaints handling — “complaints people and relatives told us they had raised had not been recorded, investigated or acted on...People and their relatives had not received any outcome”
criticalConsent / capacity — “provider had still not explored or obtained evidence, that those making decisions on their behalf had the necessary legal authority to do so”
criticalPerson-centred care — “people and relatives continued to tell us they had not had care reviews or been involved in their care planning”
criticalIncident learning — “Incidents were not consistently audited, recorded or acted on...concerns were not always identified and appropriate actions had not always been taken”
criticalLeadership — “provider had not operated in an open and transparent way about the level of service they provide...initially told us there were 12 people using the service...we later established...at least 92”
moderateStaff training — “provider's training records recorded all staff had completed practical moving and handling training, some staff told us they had never completed this”
moderateStaff competency — “Although some staff members understanding and communication in English was limited the training provided was predominately on-line which was presented in English”
moderateSupervision / appraisal — “Spot checks to confirm staff were working in line with the provider's expectations had not routinely been completed for all staff”
moderateCommunication with families — “staff did not always have clear information about people's communication needs...some staff members spoke in their own language and did not communicate with them”
moderateInfection control — “provider could not be assured staff were following safe practices adhering to the correct use and disposal of PPE...some people told us staff did not always wear PPE”
Strengths
· Staff told us the PPE they needed was available to them and most people confirmed staff wore appropriate PPE.
· Some people with regular staff members gave positive feedback and had good interactions with staff.
· An on-call system was in place allowing people to speak to someone out of hours.
· Staff told us they knew what to do if they had concerns about a person's health or if there was a medical emergency.
· The provider was displaying their most recent inspection rating as required by law.
Quality-Statement breakdown (22)
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongInadequate
safe: Using medicines safelyInadequate
safe: Assessing risk, safety monitoring and managementInadequate
safe: Preventing and controlling infectionInadequate
safe: Staffing and recruitmentInadequate
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawInadequate
effective: Staff support: induction, training, skills and experienceInadequate
effective: Ensuring consent to care and treatment in line with law and guidance
First rating inspection of Sentricare Birmingham, a domiciliary care agency supporting 240 people, rated Requires Improvement overall due to frequent late calls, unclear medication support records, PPE concerns and mixed feedback on staff attitude and complaints responses. Effective, responsive and well-led were rated Good, with strengths in training, person-centred care planning, safeguarding awareness and quality assurance systems.
Concerns (8)
criticalMissed or late visits — “Some people and their relatives expressed frustration that they had often experienced late care calls... one person said staff had been three hours late for their lunchtime call.”
moderateMedication management — “People's care records did not always identify the level of support they needed from staff with their medicines. This increased the risk of people not receiving the help they required”
moderateInfection control — “two people said staff did not always wear masks when providing their support.”
moderatePerson-centred care — “some people raised concerns about staff members' attitude and approach towards their work. One person said some staff could be rude towards them.”
moderateComplaints handling — “one person said, 'I have complained, and nothing happened.' Another relative said, 'Staff show up extremely late... I have complained about this, but nothing has happened.'”
moderateStaffing levels — “they had met with the local authority to discuss potential solutions to staffing difficulties and the punctuality of people's calls.”
minorRecord keeping — “Some people expressed frustration over lack of access to their care records, which were held electronically.”
minorGovernance — “Spot checks to confirm staff were working in line with the provider's expectations had not routinely been completed since the start of the Covid-19 pandemic”
Strengths
· Staff understood how to identify and report abuse and knew how to raise safeguarding concerns
· Risk assessments were completed and plans developed to manage risks associated with people's care needs
· Staff received an induction, ongoing training and updates including specialist training from external healthcare professionals
· Care plans were person-centred, reflected assessed needs and were kept under review
· People's cultural and religious needs were assessed and addressed
Quality-Statement breakdown (22)
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Learning lessons when things go wrongNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough and access healthcareNot rated
Inadequate
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires improvement
caring: Ensuring people are well treated and supported; respecting equality and diversityInadequate
caring: Supporting people to express their views and be involved in making decisions about their careInadequate
responsive: Meeting people's communication needsInadequate
responsive: Improving care quality in response to complaints or concernsInadequate
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesInadequate
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsInadequate
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsInadequate
well-led: Continuous learning and improving careInadequate
well-led: Working in partnership with othersInadequate
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringInadequate
Inadequate
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires improvement
effective: Staff working with other agencies to provide consistent, effective, timely careGood
caring: Ensuring people are well treated and supported; respecting equality and diversity; respecting and promoting people's privacy, dignity and independenceInadequate
caring: Supporting people to express their views and be involved in making decisions about their careInadequate
responsive: Improving care quality in response to complaints or concernsInadequate
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesInadequate
responsive: Meeting people's communication needsInadequate
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsInadequate
well-led: Continuous learning and improving careInadequate
well-led: How the provider understands and acts on the duty of candourInadequate
well-led: Promoting a positive culture that is person-centred, open, inclusive, and empoweringInadequate
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsInadequate
well-led: Working in partnership with othersInadequate
Inadequate
effective: Supporting people to eat and drink enough to maintain a balanced dietInadequate
effective: Staff working with other agencies to provide consistent, effective, timely careInadequate
caring: Ensuring people are well treated and supported; respecting equality and diversity; Respecting and promoting people's privacy, dignity and independenceInadequate
caring: Supporting people to express their views and be involved in making decisions about their careInadequate
responsive: Improving care quality in response to complaints or concernsInadequate
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesInadequate
responsive: Meeting people's communication needsInadequate
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsInadequate
well-led: Continuous learning and improving careInadequate
well-led: How the provider understands and acts on the duty of candourInadequate
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringInadequate
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsInadequate
well-led: Working in partnership with othersInadequate
effective: Assessing people's needs and choices; delivering care in line with standardsNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: Planning personalised care to meet needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: End of life care and supportNot rated
well-led: Promoting a positive, person-centred culture and duty of candourNot rated
well-led: Managers and staff being clear about roles, performance, risks and regulatory requirementsNot rated
well-led: Engaging and involving people, the public and staffNot rated
well-led: Continuous learning and improving careNot rated
well-led: Working in partnership with othersNot rated