Tamworth Home Care Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The service was not safe and had deteriorated to a rating of inadequate. At this assessment we found there were continued breaches of the regulations relating to safe care and treatment and staffing. The provider had failed to make the required improvements. Risks associated with people’s care had not been consistently assessed or managed. Staff had not always been provided with the information and guidance required to mitigate risks and keep people safe. The provider had failed to keep a full record of safeguarding concerns, accidents, incidents or near-misses and so we were unable to assess the effectiveness of learning when things went wrong. Systems and procedures in relation to people’s medicine required improvement. Some staff lacked understanding in relation to safeguarding and whistleblowing. However, some people and their relatives felt safe with receiving care calls and found their care calls were generally punctual and reliable, but this was not everyone’s experience. Staff felt positive about recent management changes.



The service manager and business consultant had identified some areas where improvements were needed but had not yet had time to implement these. Both were receptive to our feedback.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Feedback from people using the service and their relatives did not consistently reflect a learning culture. Not everyone had needed to raise a concern or complaint but where some people and relatives had, overall, they had felt no improvements were made. One relative told us, “I have phoned the management staff at the office so many times about different issues, like staff training that need to be improved on, I was told by the deputy care manager that they would sort it out, but it is lip service really as nothing changes.”

The provider did not demonstrate a learning culture. Following our last inspection, the provider had told us they had oversight of their care call electronic live system and logged into this from their home. At this assessment we found no evidence of the provider logging in to have oversight of care calls or having undertaken any audits of any systems or processes. The provider told us, “I had trusted [Name] and admit I did not have oversight; I had a lot going on. But staff could phone or message me if needed.” Feedback from staff and leaders showed there were inconsistencies in the approach to learning, as the provider had not modelled how incidents should be investigated robustly and learned from. Feedback from staff showed they did not always have the skills, knowledge, competency, or confidence to ensure from safety incidents took place. For example, on call support staff had directed care staff member reporting missing medication “not to worry about it”.

Staff told us the service manager had started to make some improvements. However, these needed to be fully implemented, embedded and sustained before we could determine if these successfully demonstrated a learning culture.

We found no evidence that the provider fully understood and carried out their responsibilities under the duty of candour and had failed to learn from our last inspection. At this assessment, the service manager and provider’s business consultant told us they were not compliant with the regulations and were in the process of reading their CQC inspection report from July 2023 to create a service improvement plan to address the areas of concern which remained outstanding. The provider’s business consultant told us, “The service improvement plan is work in progress and we are merging outstanding things from the last CQC report, with issues the local authorities have flagged and will incorporate feedback from this assessment.” Despite people and their relatives informing us about issues they had raised, we found the provider’s concerns and complaints log was empty which meant they had failed to ensure issues, when raised by people and relatives, were recorded and acted on in a timely way and analysed so risks of reoccurrence were reduced.

People did not always experience continuity in the staff who provided their care. Some people told us they had different staff, and this had a negative impact on their care needs be met safely and effectively. Some people felt staff would call their GP on their behalf if needed.

Improvement was needed to ensure safe transitions between services. The provider had recently accepted over 40 packages of care when a local provider had closed their service. Some staff had also transferred with people’s packages of care. One staff member told us they had received no induction training for working with Tamworth Homecare.

Local authorities who commissioned services from the provider shared with us they had undertaken quality monitoring visits during 2024. Areas for improvement, including risk management, had been identified and the provider had taken on a business consultant to support them to address shortfalls in the service and implement improvements where needed.

Improvement was needed when new people were accepted by the management team to the service. Where people or their relatives had shared information about health conditions or allergies, accurate information was not always documented by staff. There was no process in place to ensure healthcare professional input was sought when needed and used to create a care plan for staff to follow. For example, 1 person had a respiratory illness and had no care plan or risk management plan to direct staff on what actions to take if they went ‘grey or blue’ in colour due to their breathing becoming laboured.

It was of concern to us that while the provider and service manager acknowledged they were not meeting all the regulations and knowing this had taken on an additional 42 people during September 2024 when a local care provider ceased to operate. This did not demonstrate the provider had a safe and effective assessment and admission to the service process or policy. Whilst the provider had now sourced support from a business consultant this was only in the few weeks prior to our assessment.

We received mixed feedback from people about how safe they felt using the service. Some of the issues described by people and their relatives to us could place them at potential risk of harm. One person who had recently left the service told us, “I have just left because they are useless. Due to my disability, I asked them to make a quick phone call to me before the care call to keep me safe, but they just never did it.” Overall, people and their relatives felt they were safe from risks of abuse and harm when they had consistent care staff who knew them well and had the skills to do their job role. One relative told us, “I think [Name] is very safe with the carers.”

Prior to our assessment we had received whistle-blowing concerns from some staff members. These included concerns about the provider and senior management staff. During our assessment the provider told us, “My head has not been in it, I know I haven’t had the oversight.” Staff had, on occasions, tried to report concerns but a staff told us it “fell on deaf ears.” This had led to delays in effective reporting and investigations being commenced. The safeguarding manager told us, “Before me in this role, staff didn’t really have a named person to report any safeguarding concerns to, so things were missed, I’ve now addressed that, and it is working.” Staff confirmed they now felt able to report concerns and knew who the safeguarding manager was. Staff were positive about the service manager who had started their employment during August 2024. One care staff member told us, “The new manager has an open-door policy, I like this approach. I think we are encouraged to shared things and speak up.” Another staff member told us, “Personally, I have had three managers during my time working here and it is only now that I think we are going in the right direction.”

The provider had failed to consistently adhere to their own policy and procedure on handling safeguarding incidents. One local authority (LA) shared information with us about the provider’s policy and actions taken following a safeguarding concern which had satisfied them the incident had been addressed. However, on our assessment we found the provider had failed to follow their own policy and actions agreed with the LA, which placed the person at potential risk. We shared our findings with the local authority. The provider had failed to have oversight of safeguarding concerns to ensure that local authorities and CQC were notified in a timely way as required. One person had been placed at risk of abuse and harm when concerns raised had not been acted on in a timely way. This person had needed to receive medical treatment because their specific dietary needs had not been followed by a staff member. Where there had been incidents of missing medicines, the provider had failed to ensure these were reported to the police. Effective processes were not in place to record any concerns raised to the management team about risks of potential and avoidable harm to people. We raised an organisational safeguarding alert to 1 local authority regarding a risk of potential harm identified to us during feedback to us from people and relatives.

The provider had no system in place to assess and monitor the quality and outcomes of safeguarding investigations. The safeguarding manager had only recently been appointed and told us, “I now have time to ensure processes are followed and have created a forum by which staff can report concerns. Before, when I was doing this role jointly being a carer as well, I might not know of any concerns until weeks later or not know at all. I want to do the job properly; I’ve told the provider this.” The safeguarding manager had commenced investigations of further safeguarding concerns and was following processes to ensure people were kept safe.

Risks associated with people’s care were not always managed safely, as some people felt at risk of injury due to, for example, staff’s lack of knowledge. People and relatives also commented on staff’s lack of effective training. We had been informed by a relative of an incident where 1 person was, “hanging out of their sling when being transferred by staff using a hoist.” This relative went on to tell us about a further incident where 2 staff had been sent to care for their relative but did not have the training needed to use the hoist sling needed. Another relative told us, “My loved one only feels safe when they recognise the carers. The are often frightened by carers who do not know how to use the sling and hoist safely.”

Most people and relatives told us they did not have consistency in their care staff which meant staff did not know them well. One person told us, “Staff ask me what I want doing because they don’t know me, it’s getting me down.”

Some people and relatives could recall being involved in their care planning and risk management whereas others could not. One relative told us, “Staff come out to do a review once a year and ask loads of questions.” Another relative told us, “[Name] has a care plan but there are mistakes in it, I’ve told them, but no one gets back to me. We’ve never had any face-to-face meeting; the agency just does the care plan and risk management with no review involving us.”

Where staff and leaders own knowledge was lacking, this impacted on their ability to support people to manage risks safely or to give the appropriate instructions to care staff. For example, staff had contacted the on-call support staff member to ask their advice on what to do because a hoist used to transfer a person was not working on their care call. Staff were directed to ‘lift’ the person, but no further guidance was given. The safeguarding manager told us, “This should not have been the case and clearer guidance should have been given or the on-call staff member should have gone to support the staff.” When we asked a staff member which emergency service, they would ask for in the event of an emergency they told us, “NHS” which meant leaders had not checked staff’s knowledge in managing risks and dealing with potential emergency situations. Some staff members knew people well if they undertook consistent care calls to people and could tell us how they effectively managed risks. One staff member told us, “I have been supporting [Name] for about 4 years and they have the same health condition as my family member, so I know exactly what to do and how to support them and what makes them worse. I know when I would need to call an ambulance or when I could offer them their medicine.”

Risk management processes were ineffective to ensure staff consistently had access to personalised, detailed and up to date information about the person they were supporting. We found some improvement had been made in the detail provided in some people’s plans of care and risk management, however, other people’s either lacked sufficient detail or no guidance was in place where needed. Information in care plans about skin care, for example, was generic and not personalised to the person themselves. Other care plans contained conflicting information which meant staff could not be sure if it related to the person they were supporting. For example, in 2 different plans of care and risk management we found a different person’s name was referred to and this included important information about allergies.

People and their relatives did not always feel staff created a safe environment. One relative told us, “We are never asked permission for new staff to come and observe and frankly 3 care staff in the bedroom is overcrowded and petrifying my relation.” Most people and relatives felt training needed to be improved on so that staff undertook tasks safely within the environment. For example, numerous concerns were shared with us about staff’s moving and handling practices.

The provider had not ensured staff knew what to do in challenging situations, such as being able to continue to ensure care calls took place if their IT system failed. While the provider had a business continuity plan, 2 senior staff spoken with did not know where this was located or what to do in emergencies. When we asked staff how they would prioritise people’s care calls if there were insufficient staff available on a given day, 1 senior staff member told us, “We have a ‘RAG’ (Red, Amber, Green) rating system on the live system.” However, staff could not locate a printed version of this to be able to refer to, in the event of a system failure.

Effective processes were not in place to ensure safe environments were maintained. Premises risk assessments had been completed and were in people’s care records. However, improvement was needed to ensure some because not all potential risks had been included. For example, a person was prescribed and used Oxygen 24 hours daily but there was no mention in their assessment of the potential risks to the Oxygen use posed by their partner being a smoker. Care plans instructed staff to check moving and handling equipment prior to use, but this did not include checking pressure relieving equipment such as special mattresses and there was no guidance to inform staff of what setting they should be on or the action to take if they were not working.

The business continuity plan stated, ‘this plan should be exercised at least annually to ensure that procedures and contact details are kept up to date’ but we found the last recorded exercise was dated February 2022.

On the second day of our assessment, the service manager showed us a printed copy of the RAG rating, which showed 72 people listed as high priority (rated red), but none had a contact number listed which meant staff did not have information to contact people, in a timely way, if their IT system failed and care calls were delayed.

We received mixed feedback from people and their relatives. Some feedback was positive. For example, 1 relative told us, “The staff stay for the full amount of time and always ask [Name] what they want. If they have extra time, they will sit and chat and tidy up, they are very friendly and caring.” However, most feedback meant improvements were needed. One relative told us, “There are so many changes in staff, no regular carers.” This theme was commented on by further people, with 1 person telling us, “I have lots of different carers, I can’t bond with them (due to different staff each care call).” And, another person said, “This week we had the same carers for 3 days which is extremely unusual.”

People and relatives felt staff did not always have the skills or knowledge for their job role. We were given an example of when this had placed a person at risk of potential harm, which we shared with the service manager so action could be taken. One person told us, “Staff don’t know what they are doing.”

Some people told us that staff shared grumbles with them about their employer. For example, 1 person told us, “Staff are fed up, they get sent all over the place and have no travel time (between care calls).” Some people told us they felt staff were rushed during care calls and we also received some negative feedback about the timing of care calls and they were not always taking place at the agreed times. One relative told us, “I’ve had staff leave from a morning care call and then staff arrive for a lunch care call in under an hour between the care calls.”

A member of the management team shared concerns with us about policies and procedures not always being applied consistently to all staff by the provider. They told us, “It shouldn’t matter who you are, but policies should apply equally to everyone.” Another member of the management team told us they did not always agree with the decisions about staffing made by the provider but felt they had to go along with these.

Care staff felt positive about the service manager. One staff member told us, “If you had asked me about what was positive about working here before the new manager, I would have said there were not many. Now everything has changed, it is organised, has a better structure and things get done.” Another staff member told us, “The new manager has an open-door policy, I like that approach. We are encouraged to share things and speak up; it’s changed how I feel about working here.”

The provider’s processes to ensure staff employed continued to demonstrate they were suitable to remain in their job role were ineffective. Where allegations and incidents related to staff had occurred, these were not effectively investigated and members of the management team told us the provider had, on occasions, actively intervened to stop some investigations. This meant investigations to identify potential staff risks had not always taken place.

Risk assessments were not always in place on staff’s files where needed. For example, 1 staff member (aged under 18 years) had no risk assessment on their staff file detailing what tasks they could and could not do. Of the 8 staff files reviewed, none had a risk assessment in place for lone working. Where a staff member had shared details with the provider about a health condition, there was no risk assessment in place for this. The service manager told us they had devised templates to be completed for these, but this was work in progress and had not yet been completed.

Improvement was needed to the provider’s processes to ensure the safe recruitment of staff. We found gaps in employment were not always recorded, and new references were not always sought when people returned to employment after leaving.

The service was registered for supporting the specialist service user band of people with a learning disability and / or autistic people. However, staff had not completed any of the required training to enable them to provide care and support to people living with learning disabilities and / or autism. The provider’s business consultant told us this had been identified as an improvement needed but had no planned date for staff training.

Staff had equity of access to the provider’s training but the training itself required improvement to ensure it had the desired outcome of equipping staff with the skills and knowledge they needed for their job roles.

People shared mixed views of their satisfactions with infection prevention and control. Most people told us staff wore Personal Protective Equipment (PPE) including gloves and aprons, but not everyone saw staff wash their hands. However, 1relative told us, “Staff do not always wear PPE. Last week we had a carer who was coughing and told us they had a cold. They had no face mask, so we had to give them one to wear.” This meant staff did not always consider actions they should take to reduce risks of spreading infection.

Prior to our assessment, a staff member had contacted CQC to share concerns with us about IPC and the same gloves being worn firstly for personal care and secondly food preparation. We discussed this concern with the provider who told us they were aware of the issue but did not know which staff member the concern related to. We found no robust action or investigation had taken place to address this risk of cross infection. Following our feedback, an investigation was undertaken by the service manager.

A staff member told us they used ‘dry wipes’ to wash people instead of soap and water. This meant not everyone’s experience would be positive because they would not effectively be washed, and a dry wipe posed potential risks of cross infection. We discussed this with the service manager who was unaware of this practice and immediately sent a message to staff to remind them to use soap and water to wash people unless a person’s care plan specified differently.

The systems in place to assess, monitor and improve staff’s compliance with the IPC policy were not effective. Timely action was not taken by the provider when IPC concerns were identified. The provider had an IPC policy in place, but this was not consistently followed by staff. For example, this directed staff to have short fingernails. IPC spot checks on staff were in place, and whilst these found some improvement in staff now putting on their PPE inside a person’s home rather than entering the care call wearing PPE, the checks had not ensured staff consistently fully adhered to the IPC policy.

Improvements had not been made since our last inspection when we found potential risks of skin damage and cross infection were posed to people by staff having long fingernails and painted nails. On this assessment, we observed 1 staff member had acrylic painted nails and when we asked them about the IPC policy, they told us, “I know I shouldn’t have them.” This staff member confirmed to us they had completed care calls that day, this posed continued potential risks of skin damage to people and cross infection. Systems to ensure staff followed policies were not effective.

Prior to our assessment we had received numerous concerns from people not receiving their medicines as prescribed and medicines going missing. At the time of the concerns being raised to us, the service manager confirmed there were no checks or processes were in place to monitor people’s medicines. Whilst some people were satisfied with the support they received with their medicines, this was not everyone’s experience and practices placed people at potential risk of harm.

Staff did not consistently follow the medication policy, prescribing instructions or manufacturer’s directions when supporting people with their medicines. The staff member responsible for medication told us, “I do get a list of some staff that need re-training in medicines but am not always told the reason so don’t know what to focus on.” This meant identified gaps in staff knowledge was not always targeted in re-training.

The service manager and safeguarding manager told us they had implemented a medicine count check for staff to complete in 1 person’s home to reduce risks of reoccurrence of missing medication. However, this had not been completed in a robust way by staff and meant actions taken to reduce risks were not checked by managers as needed.

Staff told us they had received training in the safe handling of medicines. One staff member told us, “When new carers start, after they have done their training, we watch them to make sure they are doing it properly, like checking the medicines, checking its prescribed for the right person, given at the right time and we check they fill in the records properly. The carer can’t give medication without supervision until they have been signed off. After that we check they are doing it right during our monthly spot checks. If you think the carer needs more training or help, we organise this.” They added, “Any carer who makes a mistake can’t do medication till they have retrained.”

Poor oversight of medicine management systems put people at risk of potential harm where shortfalls had not always been identified or acted on in a timely way. Where staff had not always read care notes about medicines, this had resulted in 1 person not receiving the required four-hour gap between their medicine administration. Staff did not always record the timing or dosages of administered ‘when required’ medicines which meant important information was missing to ensure people received their medicines safely. Some people were prescribed transdermal (skin) patch medicines, and we could not be assured these were administered as prescribed or as directed by the manufacturer. For example, 1 person had no body map chart recording the administration or skin site used since June 2024. Another person had a body map chart, but this had been completed incorrectly by staff showing an inconsistent approach had been taken to skin site rotation. This placed the person at risk of their medicine not being administered safely and effectively. Where people had ‘when required’ medicines, there was no personalised protocol to inform staff when to administer the medicine. One staff member told us, “[Name] has been poorly over the past few weeks and going grey and blue, I do administer [name of medicine] but there is no guidance in the care plan.”