This inspection site visit took place on 10 and 11 July 2018. Telephone calls to people, relatives and staff took place on 9, 10, 12 and 13 July 2018. The rating given at this inspection is Requires Improvement and this is the second consecutive time the service has been rated Requires Improvement.

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community. It provides a service to older and younger adults.

There were 98 people using the service at the time of this inspection.

There was a registered manager in post at the time of the inspection. 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.

We identified breaches of regulations because people’s risks and medicines were not always managed safely and systems were not operated effectively to monitor and improve the quality and safety of services provided. You can see what action we told the provider to take at the back of the full version of the report.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible.

People’s needs were assessed; though suitable care and risk management plans were not always in place to guide staff.

Care staff received the training and support they needed to deliver effective care though some staff needed additional support to complete effective assessments.

People were supported to eat and drink enough, however nutritional risks were not always suitably managed.

Improvements had been made to staffing so that there were enough staff employed to provide safe and consistent care to people. The provider had learned and made improvements in this area since the last inspection.

People were safeguarded from abuse and the spread of infection.

People were supported to access health professionals when required.

People were supported by caring staff that protected their privacy and dignity. People had support to make decisions and choices about their care.

People’s preferences were understood by staff and recorded in their care plans.

People understood how to make a complaint and the provider had a suitable complaints policy in place. We have made a recommendation about responses to complaints to ensure they are consistent and in line with the provider’s own policy and procedure.

Staff felt supported and listened to by management. The service had systems in place to gather feedback and plans were in place to improve communication with people about responses to feedback.

The service worked well in partnership with other agencies and were responsive to feedback.

Our inspection took place on 9 and 17 November 2016 and was announced.

The service provides personal care to people who live in their own homes. At the time of the inspection there were 88 people using the service. There was a registered manager in post. 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.

People’s risks had been identified, but were not consistently reviewed. People were supported by staff who had been recruited safely, but we had mixed reviews from people and their relatives about the punctuality and consistency of staff.

The principles of the Mental Capacity Act 2005 (MCA) were not consistently followed as records we viewed did not contain evidence that people’s capacity had been assessed, or if relatives were legally able to consent to care on behalf of their relations.

Some people and their relatives felt involved in the assessment, planning and review of their care and support, however records for some people were not always kept up to date. People and their relatives told us they knew how to raise a concern or complaint and we saw that the provider took action to address and resolve complaints.

People said they were cared for by staff who had the required skills to support them and to carry out personal care tasks. People received their medicines safely by trained staff. There were systems in place to check people received their medicines safely.

People told us they were given choices about what they ate and drank and were happy with the level of support provided around meals. People were supported to maintain good health and had access to healthcare when required.

People were supported by staff who treated them with kindness. People were involved in making decisions about how their care and support was provided, and staff provided support in a way that maintained people’s privacy and dignity and promoted their independence.

Staff felt supported by the registered manager and the provider through supervision, appraisal and spot checks. There were systems in place for monitoring and checking the quality of the service, however some of these were not effective in identifying areas for improvement. The registered manager demonstrated a commitment to the continuous development of the service.

We carried out this announced inspection as a follow up visit because we wanted to see if the provider had made the improvements we had asked them to make at our last inspection on 28 January 2014.

During the inspection we met with the registered manager and the provider. They helped us with the inspection and produced the records we wanted to see.

We asked the questions we always ask at inspections:

Is the service safe?

We did not assess this fully on this occasion but we saw that people’s rights were protected because assessments of their ability to make decisions for themselves were completed. When people did not have the ability to make their own decisions staff worked with people’s representatives to make decisions in their best interests’.

Is the service effective?

We did not assess this fully on this occasion but the recording of regular reviews of care and support meant that care plans were more up to date. This meant that people received care and support which met their current needs.

Is the service caring?

We did not assess this on this occasion.

Is the service responsive?

We did not assess this fully on this occasion but care records showed that people were involved in the planning of their care.

Is the service well-led?

We did not assess this fully on this occasion but the introduction of new records relating to staff supervision and appraisals meant there was now a record of the support staff received.

We inspected Ana Nursing & Care Services as part of our scheduled inspection programme. We announced the visit one day prior to the inspection to ensure the office was open.

On the day of the inspection we met and spoke with the managing director, the registered manager and the agency trainer. After the inspection we telephoned six staff to find their views of working for the company. We also spoke with people that used the service on the telephone, to find out about the standard of care and support they received.

We found that the care records had been updated and some had been reviewed, to ensure the care and support was appropriate. We found, of the 10 files we looked at, none of the service user agreements has been signed. We reviewed how the agency ensured equipment was safe to be used in people’s homes. Care staff told us they were trained and supported to use it.

We looked at how care staff were supervised and trained. The trainer described how they monitored the training needs of each individual. The care staff told us they felt well supported by the management and that they received appropriate training. We found that the supervision of care staff had not been formally recorded and the majority of care staff appraisals were overdue.

We looked at the agency’s complaint’s procedure and reviewed their logged complaints. There was one complaint being investigated. People we spoke with told us they knew how to make a compliant but they hadn’t had to do so.

We previously inspected this service in May 2012. We found that the provider had systems in place to ensure that people’s care was adequately planned to ensure their care needs were met.

At this inspection, we checked how people were supported to be involved in all aspects of their care and support. We found that people’s choices were included within their daily routines and care planning. Information about their care and the people working with them was provided.

The provider had taken reasonable steps to protect people against the risk of abuse. The provider worked in line with local safeguarding policy and procedures. Safeguarding formed part of the required training for all staff.

There were effective recruitment and selection processes in place. The provider ensured that adequate background checks had always been completed to ensure that staff working in the service were suitable to work with vulnerable people.

We carried out this compliance review because we wanted to see whether the service had made any improvements since we last visited. When we visited the service in January 2012 we told them that they needed to make improvements in outcomes 4 and 20 in order to achieve compliance in these outcomes. Outcome 4 looks at the care and welfare needs of people using the service and outcome 20 looks at whether the service notifies us of incidents such as safeguarding referrals.

Following our last inspection visit and prior to this one the service had sent us their action plan of how they intended to make improvements to these outcomes in order to achieve compliance. Along with their action plan the service also sent us copies of new records they were starting to use in respect of the care and welfare of people using the service.

This visit was unannounced. This means that the service did not know that we were coming to visit them.

Since our last inspection visit the registered manager had left and the registered providers were overseeing management of the service.

Throughout our visit one of the providers and one of the senior care coordinators were present. We held discussions with them and they explained how the new paperwork and records were being incorporated into assessment and care planning.

We also spoke with three people who use the service. We telephoned them following our visit to the office and spoke with them about the care and support they received. They were all satisfied with the service they were receiving and were complimentary about the staff who visited them.

We looked at the records of assessment and care planning in respect of three people who used the service. These contained good information that people had had their needs assessed and were receiving good quality care and support. Care was centred on the people as individuals and considered all aspects of their circumstances and immediate and longer term needs.

The service had also changed the way the they monitored notifications sent to the Care Quality Commission (CQC). The new procedure for referring notifications to CQC helped to ensure that none were missed and that all relevant incident reports were referred.

We carried out this inspection because we had not visited the service since 2008 and we did not have enough information to assess compliance. We wanted to see what life was like for the people receiving care and support from the service. We also wanted to see whether the service had made any improvements since we last visited.

During this inspection visit we looked at outcomes four, sixteen and twenty of the essential standards of quality and safety, under the regulations of the Health and Social Care Act 2008. Outcome four looks at the care and welfare needs of people using the service. Outcome sixteen looks at how the service assesses and monitors the quality of the services that people receive. Outcome twenty looks at how the service notifies us of incidents that affect the health, safety and welfare of people using the service.

This visit was short notice. This means that we told the service that we were coming to carry out an inspection but we only told them a short time before we arrived. This was because we needed to make sure that the manager of the service was present as we needed her to provide us with information.

We looked at some of the records and documentation provided by the manager at the time of our visit. We also spoke with her about the management of the service. We identified that the service needed to make improvements to the way that records were updated and maintained.

We also noted that the service had not kept us informed about referrals they had made to the local authority under their vulnerable adults policy.

Following our visit we telephoned people who used the service and their representatives. We received positive comments and people were happy with the care and support they received from the service. People said, “The girls are all very good. They know how I like things to be done.” Another person said, “They look after my relative very well.”

We telephoned some staff members and spoke with them about what it is like to work for the service. We received positive comments from staff about the way the service supported them with their training needs. Staff felt that they were equipped with the skills to meet the needs of people although there was a suggestion for more training around dementia care.