Background to this inspection
Updated
25 March 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 2 inspectors and 2 experts by experience. 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 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 were 2 registered managers in post.
Notice of inspection
We gave the service 48 hours’ notice of the inspection. This was because it is a DCA and we needed to be sure that the provider or registered manager would be in the office to support the inspection.
Inspection activity started on 27 February 2023 and ended on 15 March 2023. We visited the location’s office on 8 February 2023.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. 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 the registered managers, reablement manager and quality manager. We gained feedback from 19 members of staff, 12 people who used the services and 15 relatives. We reviewed 7 people’s care records. We reviewed training and supervision records and documents relating to the management of the service including policies and audits.
Updated
25 March 2023
About the service
Passion Tree Care Services Ltd a domiciliary care agency providing personal care to people in their own houses and flats. The service provides support to older people, some of whom may have dementia, and people with a learning disability or autistic people. At the time of our inspection there were 199 people 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.
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.
People’s experience of using this service and what we found
Right Support:
People were supported by staff who had been recruited safely.
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 supported people with their medicines in a way that promoted their independence.
Right Care:
The service had enough appropriately skilled staff to meet people’s needs and keep them safe.
People’s care, treatment and support plans reflected their range of needs.
The provider had systems to safeguard people from the risk of abuse and monitor the quality and safety of the service. We have made a recommendation to ensure documentation demonstrates this effectively.
Right Culture:
People and those important to them were involved in planning and reviewing their care.
People were cared for by staff who felt well supported by the managers.
The provider worked effectively with other professionals.
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 16 February 2021) and there was a breach of regulation. 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 improvements had been made and the provider was no longer in breach of regulations.
At our last inspection we recommended that the provider review current best practice to ensure effective quality and safety monitoring processes. At this inspection we found the provider had improved the processes.
Why we inspected
We carried out an announced focused inspection of this service on 9 December 2020. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safeguarding service users from abuse and improper treatment.
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 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 changed from requires improvement to good. 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 Tree Care Limited on our website at www.cqc.org.uk.
Recommendation
We have made a recommendation relating to effective documentation of safety and quality monitoring.