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Inspection Summary

Overall summary & rating


Updated 17 January 2017

The inspection took place on 24 November 2016. We contacted the service before we visited to announce the inspection. This was because the service provides a domiciliary care service to people in their own homes. We wanted to ensure that the manager was available to speak with us.

Complete Caring provides personal care to around 10 people who live in their own homes in Norfolk. The service provides support with other needs; however with domiciliary care the CQC only regulates personal care.

At our last inspection in October 2015, we identified a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This breach related to the management of the service. Safe recruitment practices had not been followed. There was limited monitoring to ensure that staff had the skills and knowledge to do the job well. There was limited record keeping and care planning. There were limited audits to monitor the quality if the service.

At this inspection on 24 November 2016 we found improvements had been made so the service was no longer in breach of this regulation.

There was a registered manager in place. A registered manager is a person who has registered with the CQC 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 2008 and associated Regulations about how the service is run.

However, the registered manager was no longer operating in this role. There was a daily manager who ran the service. For the purposes of this report they will be referred to as the manager. At the last inspection we were told that the registered manager would be de-registering as the manager and the manager would be applying to the CQC to become, the registered manager. However, this had not happened.

The service was not auditing the administration of people’s medicines to check people had received their medicines in the way the prescriber had intended. We found some issues with the recordings of people’s administration of medicines. This meant we could not be certain that these people had received their medicines as the prescriber intended. During our visit the manager told us of plans they would put in place to rectify this issue.

People were supported by staff who were knowledgeable in their roles and demonstrated the skills required. Staff had been safely recruited. There was a training system in place and staff had up to date training. Staff had a thorough induction to the service and their role. Staff were committed to provide a good service to people and felt supported to do this.

Staff demonstrated they understood how to prevent and protect people from the risk of abuse. Staff were mindful of this issue. The service had a procedure for reporting any safeguarding concerns. People and staff were protected from the potential risk of harm as the service had identified and assessed the risks people faced. People had assessments and reviews which were person centred.

People benefited from staff who felt valued by the service. Staff had confidence in the manager and the service they were providing. People told us they were treated in a respectful and caring way. People said they saw the same care staff at regular times, and did not have missed care visits.

Staff demonstrated that they understood the importance of promoting people’s dignity, privacy and independence. They gave many examples of a caring and empathetic approach to the people they supported. Staff formed positive relationships with the people they supported.

Staff had received training in the Mental Capacity Act 2005 (MCA) and demonstrated they understood the importance of gaining people’s consent before assisting them.

Staff assisted people, where necessary, to access healthcare services. Staff had a good understanding of people’s healthcare needs. Staff demonstrated they had the knowledge to manage emergency situ

Inspection areas



Updated 17 January 2017

The service was safe.

The service had identified, assessed and regularly reviewed the risks to people.

Systems were in place to protect people from the risk of abuse. Staff knew what to do if they had any concerns and they were confident in raising these.

People benefited from being supported by staff that had undergone recruitment checks to ensure they were safe to work in care.



Updated 17 January 2017

The service was effective.

The training, induction, and the support and development the staff received, contributed to the effective support people experienced.

People received care and support in the way they wished as staff understood the importance of gaining people’s consent.

When required people received support with food and drink.



Updated 17 January 2017

The service was caring.

People benefited from having positive and caring relationships with the staff that supported them.

Staff promoted people’s independence and gave them choice.

People had been fully involved in planning the care and support they received.

Staff understood the importance of maintaining people’s dignity and privacy and worked in a way that promoted this.



Updated 17 January 2017

The service was responsive.

People received care and support that was individual to their needs.

The service had identified and assessed people’s needs.

People were supported to avoid social isolation.

The service listened to people’s needs and concerns and responded appropriately.


Requires improvement

Updated 17 January 2017

The service was not always well led.

The registered manager was not active in the service and had not been since our last visit. This role had not been replaced.

Medication records were not being audited. However we were told of plans to rectify this.

There was a positive and open culture at the service.

The manager was accessible and approachable.