Tamworth Home Care Limited

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The service was not well led. At this assessment we found there were continued breaches of regulations related to governance. The provider had failed to make improvements to the oversight, management and governance of the service. The service was not well led, and the provider had failed to ensure effective systems and processes were in place.

The service did not have a shared vision and the provider had not consistently followed their own policies related to staffing and safeguarding concerns. Improvements were needed to demonstrate capable leadership. Effective checks and audits had not been undertaken to identify where improvements were needed to ensure a safe and quality service was provided to people.

The service manager and business consultant were receptive to our feedback and recognised improvements were needed. They agreed to impose a voluntary stop on accepting any more people for a period of 6 weeks. However, the following day they accepted a new person, but told us this person had ‘slipped through the net’ and were committed to making the needed improvements.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a shared vision, strategy and culture based on transparency and inclusion. The management team shared with us they did not always agree with the provider’s decision making. This meant the strategic direction was unclear. The management team and the provider’s business consultant were developing a service improvement plan aimed to capture areas the local authority had identified to them as needing improvement and assured us our feedback would be incorporated into the plan for improvements going forward.

Staff felt supported by the service manager and felt they were developing a more positive culture in the organisation.

The service had not always followed their own policies and procedures to demonstrate they acted on concerns raised, were open and responsive to suggestions and used quality systems to drive forward improvements in the service. For example, when incidents had been reported or concerns and complaints made, these had not always been recorded or acted on. We could not be assured a provider led an open and transparent culture was in place at the time of our assessment, however, we recognised the changes the new management team planned to implement to promote a more positive and open culture.

Improvements were needed to demonstrate consistent capable leadership. The provider told us they were available for staff to contact them, however, we found concerns shared with them had not consistently been acted on in a robust manner. The provider had acknowledged their own shortfalls in their ability to make the required improvements and had recently appointed a business consultant to support the service manager. The service manager acknowledged they had much to learn to achieve and drive all the improvements needed in the service. Staff now felt more confident and happier at work with the service manager in post and told us they felt able to raise concerns to them.

The provider had not always been open and transparent as they did not act fairly or consistently when applying their own policies across the staff team. The provider had failed to consistently have safe and effective systems in place which meant their oversight as provider and nominated individual was lacking. This did not demonstrate consistently capable and compassionate care.

Prior to our assessment, a staff member had shared concerns with us about risks of cross infection. During our assessment, we discussed this with the provider who told us, “A staff member had raised a concern to them about this.” We found no robust action had been taken to investigate. Staff told us they felt “things were now going in the right direction” since the service manager had started. The safeguarding manager had recognised that care staff had previously not had clear channels for reporting concerns and had set up a forum for reporting and felt this was working and staff were now speaking up about concerns. One staff member told us they had concerns about a senior staff member who had not reported a person’s boiler was not working but had recorded in daily notes they had ‘given a wash’. The safeguarding manager was acting on concerns raised to them. The new forum for reporting needed to be fully embedded and sustained to ensure staff spoke up consistently about their concerns.

Whilst safeguarding policies and procedures were in place and directed staff to speak up, the provider had failed to ensure systems were effective, and that when staff raised concerns these were acted on. There was a complaints policy in place for people using the service, but despite people and relatives telling us they had raised concerns and complaints, the log was blank which meant issues raised had not been recorded or acted on. There was no provider analysis of any concerns or complaints which meant any themes were not identified and there were missed opportunities to prevent reoccurrence of the same issues.

Prior to our assessment, some staff had raised concerns about the provider’s lack of oversight and not being present at the service. One staff member described things to us as “going from bad to worse”. There were no systems in place to gain staff feedback in areas such as how they felt about working for the service or promoting fairness amongst the staff team. However, since the service manager’s appointment in August 2024, staff told us they felt well supported by them. One staff member told us, “I shared some personal information with the manager, and she was understanding and didn’t ask questions, and assured me I would not have to work on specific dates.”



The safeguarding manager understood the importance of treating staff equally and adhering to policies and procedures with any investigation needed.

The provider did not consistently show a commitment to the fair treatment of staff. Whilst equality, diversity and human rights policies were in place, when a staff member had made an allegation about the professional conduct of another staff member in the workplace, the provider told us they were ‘friends and messing about’ and we were told the provider had not supported the investigation into concerns. Staff files did not evidence any flexible working arrangements in place.

Prior to our assessment, concerns had been shared with us about the provider’s oversight of the service. These included comments such as, “The provider lives abroad and hardly ever visits the service.” The provider told us staff could phone or message them if needed but acknowledged to us they had not had the required oversight of the service during the past 15 months following our last inspection when we identified breaches of regulations. They told us, “I left it to the previous manager and trusted them to do things.” We found incidents had occurred following the date the last manager had left that continued to show the provider’s ongoing lack of oversight, this included allegations related to the conduct of staff members that had not been handled effectively by them. Where staff had been delegated the responsibility of overseeing parts of the service, they did not always demonstrate sufficient understanding or knowledge to consistently fulfil their role. For example, the provider had delegated staff training to a staff member but had failed to ensure they consistently had the skills and knowledge needed to train and assess the competency of care staff. A senior care staff member undertook care calls when telling us they knew they were breaching their infection prevention and control policy. This meant feedback from staff and leaders across the service did not provide assurance or evidence of robust, effective or well-embedded governance or oversight systems and processes.

Staff told us about the care call monitoring system and how they monitored the system. However, staff confirmed there was no overall auditing of the electronic monitoring system to ensure care calls consistently took place at the agreed times.

Care staff were positive about the service manager and felt they were making progress to “get the service going in the right direction”. The service manager told us, “I do want to make the improvements needed, I know there is a lot to do.”

Governance processes were either not in place or not well established to ensure safe and good quality care. There was no evidence of effective provider oversight in areas including care planning, risk management, safeguarding, fit and proper persons employed, security of sensitive data and audits. The service manager and provider’s business consultant had started to develop some processes to check on the quality of the service, but these were not always fully effective or had not yet been implemented, embedded and sustained. Where checks had been completed these had not always identified the issues we found, which included concerns about transdermal (skin) patch application by staff. Audits of staff employment records and people’s care plans had not identified the issues we found as detailed in our assessment report. There was no system of auditing daily care notes made against tasks completed on care calls, which meant missed opportunities to identify any issues of concern. For example, we found very negative language had been used about 1 person by a staff member in daily notes.

The provider had not ensured that sensitive information was consistently held securely. At this assessment, the provider told us they believed an ex-staff member or members may be accessing and deleting information from records. When we asked how this might happen, the provider acknowledged they had failed to remove ex-staff access from their electronic records. We also found that all management staff, office and senior care staff had the same generic password which was unsafe practice and allowed those staff to access all records related to service users and all staff employed, rather than on a ‘need-to-know basis’. During our assessment immediate action was taken to address this potential data breach.

Communication and partnership working needed to be improved. While some people and relatives shared positive experiences with us about how care staff supported them well, other people and relatives shared negative feedback with us, this included comments about the lateness of their care calls. For example, 1 person told us, “The morning call should be for 9.30am but is at 11.30am or 12.00 noon, the teatime call should be at 6.00pm but is often at 8.30pm. I never received notification of the lateness.” Another person told us, “Timing of care calls is the biggest problem for me. I have explained my needs to them in the office, but they don’t listen. I ring again and again and now it’s total frustration.” A further person told us, “My biggest problem is they are always so late. The carers can’t help it, it’s the managers. The supervisors say they have emergencies, well they don’t have emergencies every day do they! I told them it is no excuse for every single day. They don’t listen.”

People’s preferences and feelings were not always taken into account by the provider with partnership working. For example, 1 relative told us, “My female relation was asked if they would have a male carer (for personal care) and they said they were very uncomfortable with this. The staff member told us they didn’t have enough (female) staff so we would just have to accept a male carer.”

The service manager and provider’s business consultant told us they were currently working with the local authority and a service improvement plan to drive forward identified improvements needed. The service manager and provider’s business consultant were open to our feedback and planned to incorporate this into their improvement plan.

At the time of our assessment, work was ongoing with commissioners to work in partnership with them with the aim of improving the standard of care. Recent improvements by the safeguarding manager in reporting incidents to commissioners needed to be embedded and sustained.

Systems and processes required improvement to ensure the management team identified and escalated concerns and referrals to other health professionals in a timely way. For example, the service manager told us 1 person had damaged skin and the district nurse was involved in their care. However, feedback from people and relatives identified a further 2 people with sore skin that the service manager was unaware of. There was no system in place to audit daily notes made by staff which meant opportunities to act on information may be missed and referrals to healthcare professionals potentially delayed. Processes for partnership working with people and their families needed to be improved on to ensure their views and wishes were taken account of.

Improvement was needed to staff training and in supporting the trainer to have the skills and knowledge needed in their delegated role. The provider had delegated care staff training to a staff member who told us, “The 300 induction slides I use are not very good really as they are for care homes. I identified this problem to the last manager, but nothing changed.” This staff member told us staff completed online modules and some face-to-face training which they delivered to staff. This staff member added, “I deliver catheter care, but have never had training in this myself.” We were informed staff had no training in certain topics such as diabetes and added, “We have issues about people having hyperglycaemia and staff not knowing what to do.”

Systems in place for the training of staff were ineffective and placed people at risk of harm. Feedback from people and their relatives included concerns about staff training and staff’s lack of skills and knowledge. Where concerns had been raised these had not always been recorded or acted on. This meant the provider and management staff did not focus on learning from when things went wrong. Investigations into incidents was not always robust.