The inspection site visit activity started on 2 November 2018 and ended on 7 November 2018. It included calls to people and their relatives to seek their views about the care and calls to staff to seek their views about working at the service. We visited the office location on 5 and 7 November 2018 to see the manager and office staff; and to review care records and policies and procedures. This was the first rating inspection for the location following registration.

We gave the service 48 hours’ notice of the inspection visit because it is small and the manager is often out of the office supporting staff or providing care. We needed to be sure that they would be in.

Ave Maria (Burntwood) 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 adults and those living with dementia, younger disabled adults and those living with a physical disability. At the time of the inspection 28 people were using the service.

There was not a registered manager in post at the time of our inspection. They had recently left the service. A new manager had been recruited and was waiting for a start date. 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 provider had systems in place to check on the quality of the service people received, however these were not consistently effective. These issues meant the provider was not meeting the regulations and you can see what action we asked the provider to take at the end of this report.

People were not always supported to have their needs met at the time of their choosing which meant people were left without the support they needed. People’s medicines were administered safely, however not always at the time prescribed.

Risks to people were assessed and planned for to keep people safe. People were supported by safely recruited staff. People were protected from the risk of cross infection. People were safeguarded from abuse. The provider learned when things went wrong.

People had their needs assessed and plan were in place to meet them. Staff were supported in their role and had access to an induction program and ongoing training. People had support which was consistent. People could choose their meals and were supported to eat and drink. People were supported to maintain their health and well-being.

People had choice and control of their lives and staff were aware of how to support them in the least restrictive way possible; the policies and systems in the service were supportive of this practice.

People were supported by staff that were caring. People were supported to make choices and staff promoted people’s independence. Peoples communication needs were assessed and planned for. People had their privacy and dignity protected.

People’s preferences were understood by staff. People had access to a range of activities. People were clear about how to make a complaint and these were responded to. People were supported to consider their preferences for care at the end of their life. Whilst the service was not supporting people with end of life care at the time of our inspection, there were systems in place to consider peoples wishes.

Notifications were submitted to CQC as required. People and their relatives told us they had noted improvements since the new management team had been in place and felt they were approachable. Staff also felt the new management team offered them support in their role. Quality checks were in place and an action plan was used to identify areas for improvement.