AA-I-Care - 35 Southwell

The assessment took place between 30 September 2025 and 15 October 2025. We visited the location's office on 30 September 2025. We gave the service notice of the inspection. This was because it is a small service, and we needed to be sure that the provider would be in the office to support the inspection. During the inspection we assessed the quality statements under all key questions of safe, effective, caring, responsive and well led. We inspected this service partially to follow up shortfalls identified at the last inspection in August 2023, and partially because of concerns received about the quality and safety of the care provided.

At our last inspection there were areas needing improvement, which included using medicines safely, assessing risk, staff recruitment, safety monitoring and management, and learning lessons when things go wrong. At the last inspection systems and processes were not in place to protect people from receiving unsafe care and treatment. Risks were not all appropriately assessed and mitigated. The competence and skills of staff to support people safely had not been assessed, and medicines were not managed safely. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At this inspection we found substantial improvements had been made in the management of risks, which were appropriately assessed and mitigated. Staff worked with people to assess any risks they faced. There were detailed risk management plans, which gave staff clear guidance on what to do to support people safely.

People felt safe and staff were aware of their responsibility to identify and report potential abuse. Staff completed safeguarding training and were confident any concerns raised would be properly dealt with. There were enough staff to meet people’s needs, and people were supported by a consistent staff team. People were complimentary about the staff and positive relationships had been developed. People had a comprehensive care plan, which they helped devise and review regularly.

There was an effective system in place to assess the competence of staff to give medicines and support people to move safely before they worked alone. Improvements had been made to the safe recruitment of staff. Staff had been recruited safely with all pre-employment checks completed prior to them starting. The provider had established a process of learning from events that had either put people and staff at risk of harm, or had caused them harm, to improve the service. Openness and transparency about safety was actively encouraged and embedded in the service. Enough improvement had been made at this inspection and, whilst some further work was needed to ensure the systems were embedded, the provider was no longer in breach of regulation 12.