From a spreadsheet nobody owned to an inspection-ready staffing file
Cherwell's training matrix was eleven months out of date across four houses. We audited 34 personnel files, found 61 gaps, and closed them before the inspection window.
61
Compliance gaps found and closed
- Service
- Four supported living houses, 34 staff
- Location
- Cherwell district, Oxfordshire
- Engagement
- Compliance audit, then ongoing monthly management
- Timeframe
- Ten weeks from audit to clear position
The situation
What we walked into
Cherwell had grown from one house to four in two years. The training matrix had been set up by a manager who had since left, and nobody had owned it since. Nobody could say with confidence how many staff held a current moving and handling certificate.
An inspection was expected within the year. The operations lead knew the care was good and the paperwork was not, which is an uncomfortable position to be in.
What we did
Four decisions that made the difference
- 01
A full audit before any promises
We reviewed all 34 files against CQC expectations and produced a written gap list: 61 items across DBS currency, missing second references, expired training and unverified right to work documents.
- 02
We triaged by risk, not by ease
Expired moving and handling and medication competency came first because those carry direct risk to tenants. Cosmetic file tidying came last.
- 03
Update Service checks did the heavy lifting
Nineteen of the 34 staff were already on the DBS Update Service, which meant status checks rather than new applications — weeks of waiting removed from the plan.
- 04
Then we kept it current
Cherwell moved onto monthly compliance management, with 60-day expiry alerts and refresher training booked before certificates lapse.
The outcome
What changed
- All 61 gaps were closed within ten weeks, with an audit trail showing when each was identified and resolved.
- The subsequent inspection raised no findings relating to staffing records or recruitment practice.
- The operations lead now gets one monthly pack rather than chasing four house managers for spreadsheets.
- 34
- Personnel files brought to standard
- 19
- Update Service checks instead of new DBS applications
- 0
- Staffing findings at the following inspection
“We knew our care was good and our files were not. CareCore told us exactly how bad it was in writing, which nobody else had done, and then fixed it in the order that actually mattered.”
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