Passionate About Care

Updated 31 August 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.

Inspection team

The inspection was carried out by one inspector. An additional inspector made phone calls to staff and two Expert by Experience’s made phone calls to people and their relatives to gain feedback. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

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 short notice of the inspection. This was because 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 reviewed information we had received about the service since the last inspection. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 16 people and 7 relatives about their experience of the care provided. We spoke with 10 members of staff including the registered manager, office staff, care workers and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also received email feedback from one member of staff and four professionals. We reviewed a range of records. This included nine people’s care records and five medication records. We looked at five staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 31 August 2022

About the service

Passionate About Care is a domiciliary care agency providing personal care to people in their own homes. The service covers three main geographical areas: Petersfield, Havant and Waterlooville. The service was supporting older people, those living with dementia, people with a physical disability and younger adults.

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. 70 people were supported with personal care at the time of the inspection.

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

The governance systems in place were not always robust and fully established to support the management team to identify and address shortfalls or to drive improvement in all areas.

Risks associated with people’s support needs and health conditions had not always been effectively assessed, monitored or mitigated. This increased the risk of harm to people. The registered manager told us of their plans to improve the management of risk.

Staff were not always effectively deployed which meant there was a risk this would have a negative impact on people’s health and well-being. The provider began making improvements at the time of our inspection to improve this for people.

Complaints and concerns had not always been used to improve the service.

Staff had received training in safeguarding and knew the actions to take to keep people safe. Overall, people's medicines were managed safely. The provider had infection control policies and procedures in place to guide staff on how to reduce the risk of infections.

Staff felt well supported through training and supervision. Staff in the service worked well with each other and external professionals to ensure good health outcomes for people.

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.

People told us they were supported by kind and caring staff who treated them with dignity and respect. However, we have made a recommendation, so people are always supported in a person-centred way.

The provider had improved governance systems since our previous inspection and had introduced new auditing systems. This had led to many improvements. However, systems and processes needed to be embedded to ensure all regulations were complied with. Staff spoke positively about leaders at the service.

The nominated individual, registered manager and director demonstrated a willingness to make improvements and during the inspection began reviewing their systems and process to ensure the service consistently provided good, safe, quality care and support. Following the inspection, they sent us an action plan. Further progress was still needed to fully embed and sustain these improvements.

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 inadequate (report published 18 October 2021). There were seven breaches of regulation in relation to regulation 17 Good Governance, regulation 12 Safe Care and Treatment, regulation 11 Consent, regulation 18 Staffing, regulation 19 Recruitment, regulation 13 Safeguarding and Regulation 9 Person-centred care.

We imposed conditions on the providers registration, and they completed an action plan after the last inspection to show what they would do and by when to improve. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Passionate About Care on our website at www.cqc.org.uk.

At this inspection improvement had been made in some areas and the provider was no longer in breach of regulation 9, 11, 13 and 19. However, not enough improvement had been made in other areas and the provider was still in breach of regulation 12 and 17 and 18. We also identified an additional breach of regulation 16 Complaints.

Why we inspected

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

The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvement. Please see the Safe, Caring, Responsive and Well led sections 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 breaches in relation to safe care and treatment, staffing, complaints and governance.

The provider has conditions on their registration which remain relevant to the findings at this inspection. We will request an updated action plan and meet with the provider.

Follow up

This service has been in Special Measures since September 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

However, because improvement is still necessary, we will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.