Passion Healthcare Ltd is a domiciliary care agency providing personal care for people in their own homes. The service provides personal care for older people and younger adults. This was a comprehensive inspection. The inspection took place on 11 and 12 June 2018. The inspection was announced because we wanted to make sure that the registered manager was available to conduct the inspection.
At our last comprehensive inspection in May 2016 we rated the service as 'Good'. On this inspection improvement was needed to ensure that people were comprehensively safe and that quality assurance systems had not been effective in driving improvements in the service. Because of these issues, the overall rating for this inspection has reduced to 'Requires Improvement.'
A registered manager was in post. This is a condition of the registration of the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.
Risk assessments were not comprehensively in place to protect people from risks to their health and welfare.
Policies set out that when a safeguarding incident occurred management needed to take appropriate action by referring to the relevant safeguarding agency and to CQC. This had not been carried out for a potential suspicion of abuse.
Management had carried out audits in order to check that the service was meeting people's needs and to ensure people were provided with a quality service, though some issues had not been checked including issues which were identified on this inspection.
Staff recruitment checks were carried out to protect people from receiving personal care from unsuitable staff.
People and relatives told us they thought the service ensured safe personal care was provided by staff. Staff had been trained in safeguarding (protecting people from abuse) and understood their responsibilities in this area.
People told us that staff supported them with their medicines and records had shown this had happened.
Staff had received training on core important topics to ensure they had skills and knowledge to meet people's needs, though training on other relevant issues had not yet been provided.
Staff understood their responsibilities under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) to allow, as much as possible, people to have effective choices about how they lived their lives. Staff were aware to ask people’s consent when they provided personal care. Mental capacity assessments were in place.
Most people and relatives told us that staff were friendly, kind, positive and caring. Not everybody told us they had been involved in making decisions about how and what personal care was needed their needs, though they did not feel this had any impact on the quality of care they received.
Care plans included important information on people’s needs, which helped to ensure that their needs were met, though there was not comprehensive information in place on people’s lifestyles and preferences.
People and their relatives were confident that any concerns they had would be properly followed up. Most were satisfied with how the service was run.
Staff members said they had been fully supported in their work by the management of the service.
We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.