# Blay Domiciliary Services

*Operated by BWA Health & Care Services Ltd.*

Blay Domiciliary Services is a CQC-regulated home-care agency in Derby.

## CQC Ratings

| Key question | Rating |
| --- | --- |
| Overall | Good |
| Safe | Good |
| Effective | Good |
| Caring | Good |
| Responsive | Good |
| Well-led | Good |

Rating published: 23/10/2025

## Practical info

- Postcode: DE1 1BT
- Registered manager: Woodhouse, Yvonne
- Local authority: Derby
- Region: East Midlands
- City: Derby
- Last CQC check: 23/Oct/2025 - 00:00

## Inspection findings

### effective

- Finding
  - Supporting people to eat and drink enough to maintain a balanced diet
  - Published: 2024-05-30
- Finding
  - Staff support: induction, training, skills and experience
  - Published: 2024-05-30
- Finding
  - Supporting people to live healthier lives, access healthcare services and support
  - Published: 2024-05-30
- Finding
  - Assessing people's needs and choices; delivering care in line with standards, guidance and the law
  - Published: 2024-05-30
- Finding
  - Ensuring consent to care and treatment in line with law and guidance
  - Published: 2024-05-30

### Other

- Finding
  - Evidence: Staff felt respected, valued and supported by management.
  - Published: 2024-05-30
- Finding
  - Evidence: Registered manager welcomed feedback and commenced addressing identified issues promptly following inspection.
  - Published: 2024-05-30
- Finding
  - Evidence: Infection prevention and control policy in place with all staff trained and supplied with appropriate PPE.
  - Published: 2024-05-30
- Finding
  - Evidence: Staff worked collaboratively with external health professionals including GPs, social workers and pharmacists.
  - Published: 2024-05-30
- Finding
  - Evidence: Effective incident recording, investigation and trend analysis to ensure lessons were learnt.
  - Published: 2024-05-30
- Finding
  - Evidence: Staff completed safeguarding training and had good understanding of abuse and reporting procedures.
  - Published: 2024-05-30
- Finding
  - Evidence: Robust recruitment systems ensuring right staff were recruited to support people to stay safe.
  - Published: 2024-05-30
- **communication_with_families** _(minor)_
  - Evidence: People and their relatives gave us mixed feedback about communication with the management team...others told us that it needed improvement.
  - Published: 2024-05-30
- **staff_training** _(moderate)_
  - Evidence: "Training is not really sufficient. Not compared to the past. Some are more able than others...They're nice [carers] who would make good carers with more training."
  - Published: 2024-05-30
- **record_keeping** _(moderate)_
  - Evidence: Provider's systems did not identify all shortfalls in recording of people's care...staff did not always record their interactions and support for the person correctly.
  - Published: 2024-05-30
- **governance** _(critical)_
  - Evidence: Audits of people's care plans did not identify that they were not always comprehensive or up to date...risks were not always identified or managed appropriately.
  - Published: 2024-05-30
- **consent_capacity** _(critical)_
  - Evidence: People had no mental capacity assessments or best interest decisions completed...Key requirements of the Mental Capacity Act 2005 were not fully understood by staff.
  - Published: 2024-05-30
- **care_planning** _(critical)_
  - Evidence: 1 person lived with a complex condition...The risk assessments and care plan for this person were contradictory and did not provide staff with clear guidance.
  - Published: 2024-05-30
- **medication_management** _(critical)_
  - Evidence: Staff did not always record administration of medicines properly...we saw gaps in people's medicine administration records (MARs).
  - Published: 2024-05-30

### safe

- Finding
  - Preventing and controlling infection
  - Published: 2024-05-30
- Finding
  - Learning lessons when things go wrong
  - Published: 2024-05-30
- Finding
  - Systems and processes to safeguard people from the risk of abuse
  - Published: 2024-05-30
- Finding
  - Staffing and recruitment
  - Published: 2024-05-30
- Finding
  - Using medicines safely
  - Published: 2024-05-30
- Finding
  - Assessing risk, safety monitoring and management
  - Published: 2024-05-30

### well_led

- Finding
  - Working in partnership with others
  - Published: 2024-05-30
- Finding
  - Engaging and involving people using the service, the public and staff
  - Published: 2024-05-30
- Finding
  - Promoting a positive culture that is person-centred, open, inclusive and empowering
  - Published: 2024-05-30
- Finding
  - Managers and staff being clear about their roles, quality performance, risks and regulatory requirements
  - Published: 2024-05-30
- Finding
  - Continuous learning and improving care; working in partnership with others
  - Published: 2023-12-07

## Source

Data published by the [Care Quality Commission](https://www.cqc.org.uk/) under the Open Government Licence v3.0. Canonical page: https://homecarecompass.co.uk/agency/1-120148760

HomeCare Compass is an independent guide and is not affiliated with the CQC.