Background to this inspection
Updated
26 August 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 1 inspector.
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 was a registered manager in post.
Notice of inspection
We gave the service 48 hours’ notice of the inspection. This was because it is a small service 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 26 July 2023 and ended on 3 August 2023. We visited the location’s office on 3 August 2023.
What we did before 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.
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.
During the inspection
We spoke with 3 relatives about the care provided to their relative. We spoke with 2 care staff and the registered manager.
We reviewed a range of records. This included 4 people's care records. We looked at 1 staff file in relation to recruitment. A variety of records relating to the management of the service, including policies, procedures and audits were reviewed.
Updated
26 August 2023
About the service
Passion Domiciliary Care Limited, provides personal care within people’s own houses and flats. At the time of our inspection 6 people, were 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.
People’s experience of using this service and what we found
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.
At the time of the inspection, the location did not care or support for anyone with a learning disability or an autistic person. However, we assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group.
Right Culture: The provider’s governance was ineffective to ensure the inclusion of equality and diversity during the assessment and care planning process. Monitoring systems did not identify the absence of training regarding specific needs of people from different ethnic groups and those who had a diagnosis of diabetes. The governance did not identify the relevance of medicines training to ensure the registered manager had the skills to carry out medicine competency assessments.
Staff knew and understood people well and were responsive, supporting their aspirations to live a quality life of their choosing. Staff supported people to be independent and to ensure their safety whilst doing so.
Right Support: 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 support this practice.
Right Care: People received kind and compassionate care. Staff understood how to protect people from poor care and abuse. The service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
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 27 July 2021). The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.
Why we inspected
We carried out an announced comprehensive inspection of this service on 15 June 2021. A breach of legal requirement was found and the provider was issued a warning notice. The provider completed an action plan after the last inspection to show what they would do and by when to improve good governance.
We undertook this focused inspection to check whether the provider had complied with the warning notice, 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 remained as requires improvement. 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 Domiciliary Care Ltd on our website at www.cqc.org.uk.
Enforcement
We have identified a breach of regulation in relation to good governance at this inspection.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.