Alters Recruitment Limited t/a Alters Nursing - London provides personal care to people and children in their own homes. At the time of this inspection, 81 people were using the service which included three children.

There was a registered manager at the service. 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 2008 and associated Regulations about how the service is run.

At the last inspection in November 2015, we found one breach of the regulations because risk assessments were not robust and did not identify or address all risks faced by people receiving a regulated activity. We asked the provider to take action to make improvements and this action has been completed.

At the last inspection, we also found that people’s medicines were not always managed safely to ensure that people received their medicines as prescribed. The provider took action to improve this during the last visit and these improvements had been sustained.

Support needed to meet nutritional and hydration needs was not always clearly recorded. However, during this inspection, we found this had improved. At the last inspection, the service did not always respond to complaints appropriately but at this inspection we found this had also improved.

Quality assurance systems were in place but were not always effective. During this inspection we found improvements had been made and quality checks showed the action taken to resolve identified issues.

During this visit we found staff were knowledgeable about safeguarding and whistleblowing procedures. The provider had safe recruitment procedures in place to ensure appropriately skilled and experienced staff were employed. Staff were offered regular training to make sure their skills were up to date and staff received regular supervisions and appraisals.

People’s care plans showed the service worked with healthcare professionals and staff were aware of people’s nutritional needs. Staff worked within the requirements of legislation and obtained consent from people before delivering care.

People and relatives thought staff were caring and they felt listened to. Staff demonstrated they were aware of how to respect people’s privacy, dignity and independence. The provider had a complaints policy and dealt with complaints in accordance with this policy. The provider also kept a record of compliments made about the service.

The provider asked people to give feedback on the quality of the service provided and people and their relatives thought the manager was approachable. Staff regularly attended staff meetings and the provider carried out spot checks on the work staff carried out.

The inspection took place on 18, 20, 23 and 26 November 2015 and was announced. The provider was given 48 hours’ notice as they are a domiciliary care agency and we needed to be sure someone would be in. The service provides support to approximately 60 people living in their own homes.

The service had a registered manager. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

People gave us mixed feedback about the service, some were happy while others felt that communication with the office was poor. People felt safe and the service had safeguarding policies and procedures which were understood by staff. Care files contained risk assessments, but these were not always robust and did not provide staff with the information they needed to reduce the risk of harm to people. The provider took action to address this during our inspection. Where the service supported people with their medicines this was done by trained staff, however the recording systems in place were not sufficient to ensure that people were taking their medicines as prescribed. The provider took action to address this during our inspection.

People received support from the same staff, however they told us that cover arrangements were not always made or communicated to people and their families. We have made a recommendation about staffing levels.

Staff recruitment was safe, with appropriate pre-employment checks being completed by the service. However, the service employed staff who were unable to provide two employment references and this was not addressed by the recruitment policy. We have made a recommendation about recruitment practices.

Staff received a thorough induction, on-going training and supervision and told us they felt supported in their roles.

Records showed that people consented to their care in line with legislative requirements. People and staff told us that people were supported to eat and drink enough to maintain a healthy, balanced diet and where necessary were supported to access health care professionals. However, this was not always clearly recorded in people’s care plans and records of care. We have made a recommendation about care files.

Staff developed positive relationships with the people they supported, and people described their staff as caring. The service provided staff who could meet the cultural and linguistic needs of people using the service. Staff demonstrated a good understanding of people’s cultural and religious needs.

People had regular reviews of their care and were given the opportunity to provide feedback about their care at regular intervals. The service did not always respond to complaints or provide feedback to people in a way that was understood.

The quality of care records varied. Some were highly personalised while others were task focussed. The service was taking action to address the inconsistencies.

The service did not consistently demonstrate good leadership and management. Some people and staff were very positive about the registered manager, whereas others were not able to identify who they were. The quality assurance and audits completed had led to action plans, however, the plans had very long timescales which meant that change was not achieved in a timely manner. We have made a recommendation about improvement planning.

We identified one breach of the regulations during our inspection. You can see what action we have told the provider to take at the end of the report.

People told us their care workers respected them. One person told us with regard to care workers showing them respect that "X does, she really is a nice woman."

One person told us their carer was "delightful, she is really lovely." One relative we spoke with told is their parent's carer was a "good" carer. People’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

People and relatives we spoke with told us they felt staff had sufficient training to undertake their roles and responsibilities. There was documentary evidence that staff had an induction before they delivered care to people. We found staff received appropriate professional development.

People we spoke to told us they felt safe with the agency's care workers. We found staff had safeguarding vulnerable adults training and understood they should report any concerns they had regarding people's safety and risk of abuse.

At our last inspection in November 2012 we found the provider did not have an effective system to regularly assess and monitor the quality of service that people receive because the views of people who used the service and those acting on their behalf had not been regularly sought. At this inspection we found there were sufficient improvements in place to adequately obtain the views of people and their relatives who used the service.

We found people who used the service felt safe with the care they received and with the care workers who delivered their care. One relative we spoke with told us they were "completely fine, we are content."

Staff were supported by management and had supervisions and appraisals. We found they had attended relevant training to fulfil their roles and responsibilities. There was evidence the provider had undertaken the necessary and appropriate checks into the good character of care workers hired to deliver care in people's homes.

People told us they knew how to make a complaint if they needed to. One person told us "if I wasn't happy, I know how to raise it."

However we found the agency did not regularly seek the views of people who used the service or those acting on their behalf about the quality of the service and they did not regularly assess and monitor the quality of care provided by care workers.