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Inspection Summary

Overall summary & rating


Updated 24 June 2016

Passion Healthcare provides personal care for people living in their own homes. On the day the inspection the manager informed us that there were 36 people receiving personal care from the service.

We previously carried out an unannounced inspection of this service in November 2013. Breaches of regulations was found relating to a failure to fully promote people's welfare, checking that staff were fit to provide personal care to people and a lack of quality checking of services supplied to people.

After this inspection we asked the provider to produce an action plan stating what they would do to meet legal requirements in relation to the breaches. The provider sent this to us. This outlined action that would be put in place to ensure that these breaches in regulations were rectified. We found action had been taken to meet these breaches.

A registered manager was not in place. A registered manager is a person who has registered with the Care Quality Commission 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 and associated Regulations about how the service is run. The current manager stated that she would submit an application to be the registered manager of the service within a month of this inspection visit.

People and their relatives we spoke with said they thought the agency ensured that people received safe personal care. Staff had been trained in safeguarding (protecting people from abuse) and staff understood their responsibilities in this area.

Risk assessments were detailed to assist staff are to support people safely.

We saw that medicines were supplied safely and on time, to protect people’s health needs.

Staff had been safety recruited to ensure they were appropriate to supply personal care to people.

Staff had training to ensure they had the skills and knowledge to be able to meet people's needs, though more training was needed to ensure all people’s needs could be met.

Staff understood their responsibilities under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) to allow, as much as possible, people to have effective choice about how they lived their lives.

Staff had awareness of people's health care needs so they were in a position to refer to health care professionals if needed.

People and their relatives we spoke with told us that staff were friendly, kind, positive and caring.

People, or their relatives, were involved in making decisions about how personal care was to be provided.

Care plans were individual to the people using the service is to ensure that people's individual needs were met to ensure a fully personalised service was provided to them.

People or their relatives told us they would tell staff or management if they had any concerns and were mostly confident any issues would be properly followed up.

People and their relatives were satisfied with how the service was run by the management. There were comments for improvement from staff to ensure they were fully supported in their work.

Management carried out audits and checks to ensure the agency was running properly and ensure people were provided with a quality service.

Inspection areas



Updated 24 June 2016

The service was safe.

People and their relatives said that people felt safe with staff from the service.

Risk assessments to protect people's health and welfare were in place.

Staff were aware of how to report incidents to their management.

Staff recruitment checks were in place to protect people from receiving personal care from unsuitable staff.

Medicines had been supplied as prescribed and action taken to protect the person's health if an error in supplying medicines had taken place.



Updated 24 June 2016

The service was effective.

Staff were trained to meet people's care needs though more training was needed to ensure that all people’s needs were met.

People's consent to care and treatment was sought in line with legislation and guidance.

People's nutritional needs had been promoted and protected.



Updated 24 June 2016

The service was caring.

People and their relatives told us that staff were friendly and caring and respected their rights.

We saw that people or their relatives had been involved in setting up care plans that reflected people's needs.



Updated 24 June 2016

The service was responsive.

Care plans contained information on how staff should respond to people's assessed needs.

People and their relatives were mostly confident that any concerns they identified would be properly followed up by the provider.

Staff were aware of how to contact medical services when people needed health support.



Updated 24 June 2016

The service was well led.

A registered manager was not yet in post though the current manager was in process of making an application to the Commission.

People and all relatives except one told us that management listened and acted on their comments and concerns and they thought it was a well led agency.

Staff told us the manager and senior office staff had provided support to them.

Staff said the manager had a clear vision of how friendly individual care was to be provided to people to meet their needs.

Systems had been audited in order to measure whether a quality service had been provided.