Background to this inspection
Updated
1 June 2023
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.
Inspection team
The inspection was carried out by 1 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 provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post.
Notice of inspection
We gave the service 48 hours’ notice of the inspection. This was because it is a small service and we needed to be sure that the provider or registered manager would be in the office to support the inspection.
What we did before the inspection
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 registered manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We looked at a range of records which included the care record for 2 people, 3 care workers’ files and a range of records including those used for monitoring the quality of the service, such as audits and policies. Following the inspection, 2 relatives provided feedback via email and we received feedback from 4 care workers.
Updated
1 June 2023
About the service
Passion Recruitment Agency is a domiciliary care service providing personal care and support for people in their own homes. At the time of the inspection, they were providing support with personal care for two people.
People’s experience of using this service and what we found
People’s risks were identified but staff were not always provided with guidance with actions they could take to reduce the possible risks. When a fall occurred care plans and risk assessments were not always updated and effective actions to reduce possible risk were not always identified. The provider had a process for the administration and recording of medicines, but this was not always followed. The provider had audits in place which were used to monitor the quality and recording of the care provided but these were not always robust enough to identify issues requiring action. We have made a recommendation for the provider to review the guidance on managing medicines in the community.
Relatives felt their family members were safe when they received care in their own home. The provider had made improvements to their recruitment process which enabled them to identify new staff with the required skills and experience for the role.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff completed appropriate training so they could meet people’s care and support needs. Staff felt supported by the management. People’s care needs were assessed and people with their relatives were involved in the development of their care plans.
Relatives were happy with the care their family member received. Relatives were aware of the process to raise any concerns about the care but they had not had cause to do so.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 8 June 2022). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.
Why we inspected
We carried out an announced comprehensive inspection of this service on 9 March 2022. Breaches of legal requirements were found. 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, staffing, fit and proper persons employed and good governance.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements. We have found evidence that the provider needs to make improvements. Please see the Safe and Well Led sections of this focused report.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained as requires improvement. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Passion Recruitment Agency on our website at www.cqc.org.uk.
Enforcement and Recommendations
We have identified breaches in relation to safe care and treatment and good governance at this inspection. Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.