Passion Domiciliary Care Ltd

Passion Domiciliary Care Limited, provides personal care within people’s own houses and flats. At the time of our inspection 6 people, were using the service. Not everyone who used the service received personal care. 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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

At the time of the inspection, the location did not care or support for anyone with a learning disability or an autistic person. However, we assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group.

Right Culture: The provider’s governance was ineffective to ensure the inclusion of equality and diversity during the assessment and care planning process. Monitoring systems did not identify the absence of training regarding specific needs of people from different ethnic groups and those who had a diagnosis of diabetes. The governance did not identify the relevance of medicines training to ensure the registered manager had the skills to carry out medicine competency assessments.

Staff knew and understood people well and were responsive, supporting their aspirations to live a quality life of their choosing. Staff supported people to be independent and to ensure their safety whilst doing so.

Right Support: 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 support this practice.

Right Care: People received kind and compassionate care. Staff understood how to protect people from poor care and abuse. The service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

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 27 July 2021). The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

We carried out an announced comprehensive inspection of this service on 15 June 2021. A breach of legal requirement was found and the provider was issued a warning notice. The provider completed an action plan after the last inspection to show what they would do and by when to improve good governance.

We undertook this focused inspection to check whether the provider had complied with the warning notice, and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions Safe and Well-led which contain those requirements.

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 Domiciliary Care Ltd on our website at www.cqc.org.uk.

Enforcement

We have identified a breach of regulation in relation to 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 and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Passion Domiciliary Care Ltd is a domiciliary service which provides personal care to adults with a range of support needs in their own houses and flats. At the time of this inspection the service was supporting five people with personal care.

Not everyone who used the service received personal care. 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

Infection prevention procedures were in place but there were some concerns around how some staff refusals for COVID-19 testing were being managed.

Staff had received training in administering medicines safely and regular audits of medicine records took place, but some improvements were required. Care records needed to include more detailed information on the medicines people were prescribed and competency checks needed to be completed to ensure staff were safe to administer medicines.

The provider's auditing processes needed improvement to ensure records contained enough information to guide staff about people’s support needs. Staff recruitment procedures needed improvement.

Quality assurance checks were in place but had not identified some of the concerns raised during the inspection. The management were responsive to concerns highlighted and some changes were made immediately.

People and their relatives were able to give feedback about their care in a variety of ways. Examples included care reviews and during spot checks monitoring staff performance.

People were protected from abuse and relatives told us their loved ones received safe care.

Staff had received training in infection control and demonstrated an understanding of what personal protective equipment (PPE) should be used when supporting people. People told us that staff wore PPE when coming into their homes.

People's needs were assessed and staff with the right skills helped to meet these. Staff received appropriate training to assist them in their role. There were enough staff to support people's needs, people and relatives told us they saw the same staff who were always on time. Staff supported people with their eating, drinking and to access healthcare support if needed.

There was an enthusiastic, positive and caring culture amongst staff at the service. Staff had good

knowledge about the people they supported and told us they enjoyed working at the service. People's independence was promoted and respected.

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.

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

Rating at last inspection

This service was registered with us on 26 July 2019 and this is the first inspection.

Why we inspected

This inspection was carried out due to the length of time the provider had been registered with CQC without receiving a formal rating.

We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified a breach in relation to regulation 17, (good governance) at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our reinspection programme. If we receive any concerning information we may inspect sooner.