The assessment was conducted remotely between 09 February to 23 February 2026. Reflections Community Support is a domiciliary care agency registered to provide personal care to people in their own homes. At the time of inspection, they were providing support to 16 people. The Care Quality Commission (CQC) only inspects services where personal care is provided this includes assistance with tasks related to personal hygiene and eating. Where applicable, any wider social care provided is also considered. The provider had a manager registered with the Care Quality Commission, ensuring that both the registered manager and the provider were legally accountable for the operation of the service and the quality and safety of care delivered. Governance systems were in place; however, some improvements were required to strengthen oversight. A couple of supervision records had not been completed consistently in line with organisational expectations, and a training gap was identified in relation to continence support. This shortfall was acted upon promptly, and relevant staff were provided with the required training to ensure competence in this area. Recruitment procedures were safe, with appropriate checks conducted to ensure staff were suitable to work with people using the service. People experienced punctual and consistent care, and staffing arrangements supported continuity. Infection prevention and control measures were effective, PPE was accessible, and staff followed established procedures. Medicines were managed safely in accordance with recognised best practice. Care plans were in place and regularly reviewed to reflect changes in need. The provider responded flexibly to ensure continuity and coordinated working, and information was communicated clearly while maintaining confidentiality. Complaints were managed in line with policy, with concerns acknowledged, investigated and used to improve practice. Adjustments were made to ensure fairness, equity and timely access to care and support. The provider collaborated with external professionals and community organisations, enabling coordinated, holistic care and supporting people to maintain wellbeing and community connections.
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Reflections Community Support achieved a Good rating across all five key questions at its September 2017 inspection, having successfully remediated prior regulatory breaches in staff training and governance. The service demonstrated reliable, person-centred care with strong leadership, though minor issues around audit consistency and internal office communication were noted.
Concerns (3)
moderateMedication management: “We found a safeguarding alert had been raised following a medication error that had occurred earlier on in the year. We saw this issue had been investigated and that additional training was in the process of being rolled out.”
minorCommunication with families: “"They do what they can, sometimes we can ring, they do not pass on the information, we as a family have to then chase them, this is not good."”
minorGovernance: “We saw inconsistencies in the way some audits had been carried out. The manager acknowledged they were aware of these as they were still getting acquainted with the new computerised software.”
Strengths
· People consistently reported feeling safe with care staff and described a reliable, consistent service with no missed calls.
· Previous breaches of Regulation 17 and 18 had been fully remediated with improved training, supervision, and quality assurance systems.
· Safe recruitment practices including DBS checks and reference follow-up were robustly implemented.
· Training programme significantly developed since last inspection, including links with local college, e-learning, Care Certificate induction, and nationally recognised qualifications.
· Care staff demonstrated person-centred practice, respecting dignity, privacy, independence, and cultural diversity.
Reflections Community Support received an overall rating of Requires Improvement following its July–August 2016 inspection, with breaches of Regulation 17 (governance) and Regulation 18 (staffing/training) due to significant gaps in mandatory staff training and inadequate audit trails. The service demonstrated clear strengths in safe recruitment, medicines management, person-centred care planning, and a caring approach, with people consistently reporting positive experiences.
Concerns (6)
criticalStaff training: “16 of the 20 staff had not completed the fire safety course, health and safety training and infection control.”
criticalStaff training: “one member of staff was overdue moving and handling training, safeguarding and medication training.”
criticalGovernance: “the care plan audits lacked evidence of actions taken...There were no record of health and safety, staffing and staff training audits.”
moderateSupervision / appraisal: “The registered manager told us regular 'spot checks' were carried out to assess staff's performance...However no record was kept of these checks.”
minorComplaints handling: “we brought to the attention of the registered manager the need to record all complaints, showing clearly how they were addressed.”
minorCommunication with families: “staff meetings would be better if they were held at the service office rather than in public held places where there is a possibility of conversations being over heard.”
Strengths
· Robust recruitment and DBS checks with written references obtained prior to staff commencing work
· Appropriate medicines management with MAR records completed correctly and checked monthly
· Person-centred care plans with detailed daily routines and people involved in planning their care
· Good safeguarding awareness among staff who could identify types of abuse and reporting routes
· Adequate staffing levels with familiar staff cover during sickness and holidays
Quality-Statement breakdown (17)
safe: SafeguardingGood
safe: Staffing levels and recruitmentGood
safe: Risk assessment and managementGood
safe: Medication managementGood
effective: Staff training and mandatory updatesRequires improvement
effective: Supervision and appraisalGood
effective: Mental Capacity Act complianceGood
effective: Healthcare and nutritional needsGood
caring: Privacy, dignity and independence
Good
caring: Involvement in care planningGood
caring: ConfidentialityGood
responsive: Care planning and needs assessmentGood
responsive: Person-centred and personalised careGood
responsive: Complaints handlingGood
well-led: Governance and audit systemsRequires improvement
well-led: Leadership and registered manager oversightGood