The inspection was announced and took place on 15 January 2018.

BB Healthcare is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community. It provides personal care to people with a variety of needs including older people, younger adults, people with a learning disability, physical disability and people who need support with their mental health.

Not everyone using BB Healthcare receives a regulated activity; CQC only inspects the service being received by people provided with ‘personal care’; help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided. When we inspected, 46 people were being provided with ‘personal care’.

At our last comprehensive inspection on 13 September 2016, the overall rating of the service was, ‘Requires Improvement’. This summary rating was the result of us rating the key questions ‘safe’, ‘effective’, ‘responsive’ and 'well-led' as, ‘Requires Improvement’. We asked the provider to complete an action plan to show what they would do and by when to improve the key questions is the service safe, effective, responsive and well-led to at least good.

At our last inspection for the key question, ‘is the service safe?’ we found one breach of regulation. We found people were at risk of harm due to unsafe care practices being followed, this included the use of unsafe moving and handling techniques. We also found a staff member had not followed recommended safe practice for administering medicines.

For the key question, ‘is the service effective?’ we found that the service was not working within the principles of the Mental Capacity Act (MCA). People who may not be able to make certain decisions for themselves had not been assessed to determine if they were able to do so. We also identified that there were some staff who had not received the training they were expected to have completed to ensure they knew about the safest and latest best practices in connection with people's care.

For the key question, ‘is the service responsive?’ we found people may not have received the care they required due to this not being clearly explained in their care plans.

For the key question, ‘is the service well-led?’ the service did not have the required systems in place such as policies and procedures.

At this inspection the overall rating of the service was changed to, ‘Good’. We found significant improvements had been maintained and we rated each of our key questions as being, ‘Good’.

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 were protected from abuse. Staff followed the provider’s safeguarding procedures to identify and report concerns to people’s well-being and safety.

Comprehensive assessments were carried out to identify any risks or potential risks to the person using the service and to the staff supporting them. This included any environmental risks in people’s homes, risks in the community and any risks in relation to the care and support needs of the person.

Staff were recruited safely and trained to meet people’s individual needs. Wherever possible people were only supported by staff known to them and trained to meet their needs. There were enough staff assigned to provide support and ensure that people's needs were met.

People’s needs were met where staff were responsible for supporting medicine administration and ensuring people had enough to eat and drink. Staff supported people to access healthcare services when required. Clear records were kept and issues followed up on. Staff knew how to minimise the risk of infection.

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This announced inspection was carried out on 13 September 2016. BB Healthcare provides support and personal care to people living in their own homes in Kings Lynn and the surrounding area. On the day of the inspection there were 61 people using the service who received personal care.

The service did not have a registered manager in place at the time of our inspection and has not had one since July 2016. However a new manager was in post who intends to apply to become the 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 were supported by care workers who understood the risks people could face and knew how to make people feel safe. However people were not supported in the safest and least restrictive way possible.

People were supported by a regular individual or group of care workers who they knew. People’s medicines were not always managed according to best practice guidance.

People were provided with the care and support they wanted although care workers had not been fully trained in some areas of this. People provided consent to their care when needed but their human and legal right to make decisions for themselves may be overlooked.

People were supported to consume a sufficient amount of food and fluids that promoted their wellbeing. People received support from care workers who understood their health needs.

People were treated with respect by care workers who demonstrated kindness and understanding. People were involved in determining their care and support. They were shown respect and treated with dignity in the way they wished to be.

People’s care plans did not contain all the required information to ensure their care and support was delivered as needed. People were informed on how to express any issues or concerns they had so these could be investigated and acted upon.

There had been recent changes made to the management of the service who had recognised that improvements were needed and had begun making these. Previously areas of improvement to the service had not always been recognised or acted upon.

People who used the service had the right level of information to make a decision about their care. People we spoke with told us that choices were provided and respected by staff before undertaking any care and support.

People we spoke with all had positive comments about the quality of care and support they received. One person told us that BB Healthcare was, “Excellent.” Another person told us that, “They are very good as they are pretty reliable.”

People's standard of health and welfare was maintained. Staff had access to care records to ensure that they provided people with safe and appropriate support and care. However, care records we saw did not have enough information about risk assessments in them to deliver safe care.

Effective staff recruitment was in place to make sure that people received support and safe care from suitable, skilled, and knowledgeable staff.

When reviewing medication administration records (MAR) charts, we saw evidence of accurate documentation and staff training checks to ensure that people were protected against the misuse of medication.

We did not see that an effective quality assurance system was in place. This was because the provider did not generate action plans using the results from feedback, complaints, incidents or audit to monitor and improve the quality of the service delivered.

There was no registered manager in post at the time of our inspection.

All of the people who used the service that were spoken with said that they were very happy. This was because people were treated with respect, supported by members of staff and their care needs were appropriately met. One relative told us that, “The carer is absolutely brilliant.” Another person who used the service told us that their, "Carer [is] very helpful [and] very good."

People who we spoke with told us that they were involved in all discussion of their care and support needs and were confident to raise any concerns as communication with the manager and office staff was good.

People who used the service were protected from abuse as the provider had ensured that systems and information was in place.

We found that people who used the service were placed at risk because there were gaps in staff training. This meant that staff may be delivering care and support without the most up-to-date knowledge and information.

There was an effective system in place for people to make a complaint if they wished to do so.

We considered all of the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

This is a summary of what we found:-

Is the service caring?

We saw on care plans that each person was asked about their choices and exactly how they wanted support or care to be provided. This meant that people were provided with the opportunity to follow the routines they preferred.

When we spoke with people who used the service they told us that staff were caring and, “Always give me time and treat me with respect.” One family member told us that staff always treated their relative with respect and were, “Always very helpful and kind."

We heard staff answering the telephone in a considerate and appropriate tone. Staff were always helpful and polite while expressing a knowledge of the needs of each individual.

Is the service safe?

Records showed us that risk assessments were completed for all support and care provided in a person’s home. All assessments included an evaluation for the level of risk that was presented plus any actions to be taken to reduce or eliminate such risks.

Lawful requirements under the Mental Health Act (2005) were recognised and staff expressed a full knowledge of matters relating to the Deprivation of Liberty Safeguards (DoLs). Staff had regular training in these areas to ensure their knowledge remained up to date and appropriate.

Staff were trained to recognise abuse and knew what actions to take if any incidents of abuse were suspected. People using the service told us that they felt safe and cared for.

Is the service effective?

Staff expressed a thorough understanding about the needs of people they supported. We saw that care plans reflected the choices that each person had made. Care plans had been updated regularly and people using the service told us that they had discussed their wishes and preferences with staff.

People who used the service told us that staff always knew what support and care was needed and asked before they undertook any care. This ensured that each individual was able to make decisions on a daily basis and be in control of their care at all times.

Is the service well led?

Staff explained that they undertook regular training and we saw a list of dates that showed when training was due to be updated. This meant that people were supported by a staff team who knew how to provide people's support in a safe and appropriate way.

Quality assurance systems were in place and regular monitoring of records and staff practices was carried out and recorded. Staff and people who used the service told us that they felt supported and able to discuss any matters with the manager.