Passion Healthcare Limited

Updated 23 June 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

This was a targeted inspection in response to concerns we had about staff recruitment, staff recruitment, working hours and their training.

Inspection team

This inspection was carried out by one inspector.

Service and service type

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

We gave the service 24 hours’ notice of the inspection. This was because the service is small, and people are often out and we wanted to be sure there would be people at home to speak with us.

Inspection activity started on 31 May 2022 and ended on 7 June 2022. We visited the location’s office on 31 May 2022.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

During the inspection we spoke with four members of staff; the care co-ordinator, the deputy manager, the registered manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We reviewed a range of records. This included two people's care records. We looked at seven staff files in relation to recruitment, training and support. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the registered manager to validate evidence found, which was sent to us. This included staff rotas, spot checks, meeting minutes and policies and procedures. We contacted two people who used the service to find out their experience of the care provided and four relatives. We also contacted four care staff.

Updated 23 June 2022

Passion Healthcare Limited is a domiciliary care service providing personal care to people in their own homes. At the time of the inspection the registration manager confirmed the service was providing personal care to 28 people.

CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

People’s experience of using this service and what we found

People felt safe with staff from the service. Care plans and risk assessments provided guidance for staff to follow. However, not all identified risks had been risk assessed to mitigate and reduce any identified risks. People felt safe with staff from the service. Staff understood how to protect people from the risk of harm and understood potential signs of abuse. People and relatives were involved in assessments of potential risks to safety and in identifying measures to keep them safe. Staff went through a recruitment process so that the provider only employed suitable staff.

People received their medicines as prescribed. They were protected from the risk of infections through staff working practices. People had enough staff to meet their needs. Staff undertook induction training that supported them to have the knowledge and skills to do their job well and effectively meet people’s needs.

People were provided with care and support that ensured they had good nutrition and hydration. They had access to healthcare that maintained their health and wellbeing. People were supported to have choice and control of their lives and staff supported them to do this.

Staff knew people well. People had developed positive relationships with staff which helped to ensure good communication and support. Staff respected people’s privacy and dignity and encouraged people to be as independent as possible.

People or their representatives were involved and consulted when making changes to how their support was provided. Staff knew and understood the needs of the people using the service and care was provided based on their assessed needs. Staff were responsive to changes in people's needs to ensure people received timely intervention to maintain their health and well-being.

People knew how to raise any concerns or make a complaint. The provider had a policy and procedure which involved investigation and solutions to put things right. This provided information about how these would be managed and responded to. This needed to include information about referral to another statutory body to approach if they were not satisfied with the investigation.

Systems were in place to monitor the quality of care and support people experienced through quality assurance systems and processes to drive improvements in the service, though a small number of issues have not been followed up.

People and staff spoke positively about the management and leadership of the service. People said staff were very friendly and caring, and they had good relationships with them. The service worked in partnership with external agencies to ensure people achieved good outcomes from their care and support.

Rating at last inspection:

The last inspection on 11 June 2018 rated the service as requires improvement.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 11 June 2019. Breaches of regulation 12, safe care and treatment and regulation 17, good governance were found. We issued requirement notices to the provider for these breaches. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements.

Follow up:

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk