This inspection took place on 13 and 21 March 2017. The first day of the inspection was unannounced and we informed the provider of our intention to return on the second day. We gave the provider short notice of the inspection to make sure that key staff we needed to speak with were available. At our previous inspection on 15 and 22 February, 22 March and 28 April 2016 we found six breaches of regulation. One breach was in relation to the provider not informing the Care Quality Commission about safeguarding allegations. The other breaches related to one to one formal staff supervision, the provision of respect, dignity and confidentiality for people who use the service, the need for the provider to correctly identify and address people’s needs for personal care, effective identification of complaints and the need for better systems to assess, monitor and improve the quality of the service people receive. After this inspection the provider wrote to us to say what actions they would take to meet legal requirements in relation to the breaches.

Ashbourne Healthcare Services is a domiciliary care agency providing personal care and support to people living in their own home. At the time of this inspection the provider was providing personal care services for 23 people.

The service has 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. The registered manager was present for both days of the inspection.

The provider had implemented measures to promote the safety of people who use the service, their relatives and the staff team. Staff had received safeguarding training and the registered manager reported safeguarding concerns to the appropriate organisations.

The provider’s assessments of people’s care and support needs and their home environment were up to date and provided staff with guidance about how to mitigate the identified risks. Where people received support to comply with their prescribed medicines, they received this assistance from staff with appropriate training and guidance to promote their safety.

Staff recruitment procedures were comprehensive in order to ascertain if prospective staff were suitable to work with people who used the service. People and their relatives reported that they received a reliably delivered service that offered consistency and stability through the scheduling of regular care staff.

Staff supported people’s rights to make their own choices and decisions, and asked people for their consent before they provided personal care. The provider ensured that people’s rights were protected by staff who understood the Mental Capacity Act (2005). This legislation provides a legal framework that sets out how to act to support people who do not have capacity to make a specific decision. People’s files provided recorded information about people’s capacity and care staff sought guidance from their line manager if they observed any changes in people’s ability to make their choices known.

People and their relatives stated that staff were kind and caring. Staff treated people with respect and made sure that their dignity was maintained. The provider consulted with people when they carried out assessments and developed care and support plans, in order to ensure that people’s individual needs and wishes were understood and promoted. The care and support plans showed that the provider met people’s diverse needs and enabled people to adhere to their cultural, religious and personal requirements.

The provider had systems in place to advise people of their entitlement to make complaints and fully investigate any complaints. Comments about the service, which included compliments and positive feedback fro

This inspection took place on 15 and 22 February, 22 March and 28 April 2016. The first day of the inspection was unannounced. At our previous inspection on 2 May 2013 we found the provider was meeting the regulations we inspected.

Ashbourne Healthcare Services is a domiciliary care agency providing personal care and support to people living in their own home. At the time of this inspection the provider was providing personal care services for 20 people.

The service has 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People did not always feel safe using the service and one person was intimidated by a care worker after they reported their concerns. Staff did not demonstrate a clear understanding of how to protect people from abuse and the provider did not consistently inform appropriate organisations about safeguarding concerns. Staff were not aware of how to whistleblow about any concerns relating to the conduct of the service.

Staff had received medicines training, however records showed that the policy and practices for applying prescribed topical creams and lotions were not safe.

There were sufficient staff to meet people’s needs and a detailed recruitment process was carried out prior to staff commencing employment.

We received mixed opinions from people in relation to their experiences of staff punctuality and reliability, although people confirmed that they were supported by a small number of staff so that consistency and stability was achieved.

Records showed that staff had received training but events at the service indicated staff needed additional training. The provider evidenced that staff gained practical experience of care and were monitored during a placement at a care home for nursing. However, we did not find robust systems to show that the provider checked on people’s learning after they had completed training.

Monitoring visits to people’s home included some checks in regards to staff performance and conduct but there was no evidence of one to one formal supervision, so that staff had individual support to effectively undertake their responsibilities.

Care planning records showed that people’s capacity was assessed, however staff did not appear to be familiar with the Mental Capacity Act 2005 (MCA). This meant staff did not understand the principles about people’s rights to make choices and decisions.

People were provided with the support they required to meet their needs with meals and healthcare. We received positive comments about how the provider had met the needs of people receiving palliative care.

People’s entitlement to dignity and confidentiality were not always respected. There were clear issues of concern about how some staff disregarded professional boundaries in terms of how they spoke about people who used the service and there was a lack of compassion for people who were vulnerable due to their healthcare needs.

The terms and conditions for people who were self-funding contained stringent requirements for people to report any discrepancies or queries about timesheets they had signed within four days. This did not appear realistic or sensitive to the needs of people who used the service, and did not appear to consider that the impact of their ill-health, frailty or disability could lead to extended periods when they were unable to check timesheets.

Assessments and care plans did not evidence that staff knew people’s needs and wishes well. There was a lack of details about people’s wishes, interests, cultural requirements and other preferences to enable staff to provide a personalised service.

People’s needs were assessed before they received care and this information was used

We spoke to relatives of people who use the service and also looked at written feedback. They were happy with the service provided by the agency and felt their relatives were treated with dignity and respect. One relative said that "the service is top class, they are very helpful". Another relative said "they have good back-up and are very flexible". Comments about staff ranged from "very friendly," to "the care that Ashbourne Healthcare gave my relative was exceptional."

We looked at care records of people who used the service. The care records contained an initial assessment that described their individual situation and support needs and an up to date care plan which described how that support would be delivered to them.

We looked at recruitment policies and staff files. These showed that the service was following appropriate recruitment and selection processes. Appropriate checks were undertaken before staff began to work with people who used the service. All staff underwent a criminal records bureau (CRB) check prior to starting their employment and all new staff were required to provide proof of identity, including a photograph and confirmation of any qualifications they had declared.

There were systems in place to ensure that people were protected from abuse and that they received the care they needed. Systems were in place to monitor and to make improvements to the quality of care and support provided by the agency.

We did not talk with people who use the service on this occasion. However, we were able to view questionnaires sent out by the agency; these had been completed by people. Overall, people were satisfied with the service they were receiving and were positive about the staff, their attitude, and the care given.