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Inspection carried out on 26 May 2016

During a routine inspection

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 carried out on 3 December 2013

During a routine inspection

We spoke with three people who use services and three relatives during our inspection. One person told us, “I’ve got a file and it tells me the agency telephone numbers and all you need to know.” A relative told us: "The staff have helped my family member she eats better and her health is improving. I phone the agency and leave messages and they are always passed onto the support workers. It is a very good agency." People told us that they were very satisfied with the care and support they received. One person said: “I am happier with this agency, they are very caring.” A relative told us: "The staff are really good and make my family member happy, so I am happy.” People told us that they felt safe with the support workers who visited them. One person said: “I have the same staff and know them well, they are reliable.” Another person told us, “I do feel safe, I have no concerns at all.” People told us that they knew what to do if they had any concerns or worries about the care and support they received. We found the service was non compliant around care planning, staff recruitment procedures, and monitoring the quality of service.