This inspection took place on 29 November 2017. The inspection was announced. We gave the provider two days’ notice of our inspection. This was to make sure we could meet with the manager of the service and talk with staff on the day of our inspection visit.

Bella Home Care is a domiciliary care agency, registered to provide personal care and support to people living in their own homes. The service operates across Leamington Spa, Warwick and Kenilworth. The service provides care to elderly people, and people with disabilities. There were125 people using the service at the time of our inspection.

We previously carried out an announced comprehensive inspection of this service in September 2016 when we found two breaches of the legal requirements and the service was rated Requires Improvement overall. We returned in April 2017, when we conducted a focussed inspection in the key areas of Safe and Well-led to check what action the provider had taken in respect of the breaches. At that inspection we found the provider had taken sufficient action to meet the regulations but further improvements were still required to ensure people always received their scheduled calls. The service therefore remained rated as ‘Requires Improvement’ overall. You can read the report from our last two inspections by selecting the ‘all reports’ link for ‘Bella Home Care’ on our website at www.cqc.org.uk.

Since our inspection in April 2017 we have reviewed and refined our assessment framework, which was published in October 2017. Under the new framework certain key areas have moved, such as support for people when behaviour challenges, which has moved from Effective to Safe. Therefore, for this inspection, we have inspected all key questions under the new framework, and also reviewed the previous key questions to make sure all areas were inspected to validate the ratings.

The service is required to have 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 and associated Regulations about how the service is run. At the time of our inspection there was an experienced registered manager in post. We refer to the registered manager as the manager in the body of this report.

On this inspection visit we found sufficient improvements had been sustained to people’s care and safety and in the governance of the service for the provider to meet the regulations, and for the service to be rated Good in all areas.

Staffing levels had been increased and people told us they received their calls on time. All necessary checks had been completed before new staff started work to make sure, as far as was possible, they were safe to work with the people in their own homes. People were supported by a staff team that knew them well, as the provider did not use temporary staff.

Staff received training and had their practice observed to ensure they had the necessary skills to support people. Staff treated people with respect and dignity, and supported people to maintain their privacy and independence.

People had been consulted about their wishes at the end of their life. Plans showed people’s wishes about the medical interventions they had agreed to.

People received their medicines as prescribed to maintain their health and wellbeing. People were supported to access healthcare from a range of professionals, and received support with their nutritional needs. This assisted them to maintain their health.

People told us they felt safe with the staff who supported them and that staff were kind and attentive to their needs. Prior to using the service people were assessed to ensure the service could meet their needs and people told us they felt involved in decision-making about their care and support.

Staff enjoyed working

Bella Home Care is registered to provide personal care and support to people living in their own homes. The service operates across Leamington Spa, Warwick and Kenilworth. There were 120 people using the service at the time of our inspection.

We previously carried out an announced comprehensive inspection of this service in September 2016, when we found two breaches of the legal requirements. This was because of staffing levels and the governance of the service. As a result of the breaches and the impact this had on people who used the service, we rated the key questions of ‘Safe’ and ‘Well-led’ as ‘Requires Improvement’. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for ‘Bella Home Care’ on our website at www.cqc.org.uk.

After the comprehensive inspection, the provider sent us an action plan to say what they would do to meet the legal requirements in relation to each breach. We undertook a focused inspection on the 5 April 2017 to check they had followed their plan and to confirm they now met the legal requirements. We gave the provider 48 hours’ notice of our inspection. This was to make sure we could meet with the manager of the service and talk with staff on the day of our inspection visit.

The service is required to have 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 and associated Regulations about how the service is run. At the time of our inspection there was an experienced registered manager in post. We refer to the registered manager as the manager in the body of this report.

On this inspection visit we found sufficient improvements had been made to people’s care and safety and in the governance of the service for the provider to meet the regulations. Staffing levels had been increased, and the majority of people received their calls on time.

The provider had introduced a number of quality assurance systems and processes to check the quality of service they delivered, which included staff monitoring systems and medicines checks.

However, the feedback we received from people was not consistently good, and improvements needed to be sustained and developed, to ensure people always received their scheduled calls.

Although the provider is now meeting the regulations, the service continues to be rated ‘requires improvement’ in the areas ‘Safe’ and ‘Well-led’.

This inspection took place on 19 September 2016. The inspection was announced. We gave the provider two days’ notice of our inspection. This was to make sure we could meet with the manager of the service and talk with staff on the day of our inspection visit.

Bella Home Care is registered to provide personal care and support to people living in their own homes. The service operates across Leamington Spa, Warwick and Kenilworth. There were 120 people using the service at the time of our inspection.

A requirement of the provider’s registration is that they have a registered manager. A registered manager is a person who had registered with the Care Quality Commission to manager the service. Like registered provider’s 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 time of our inspection there was a registered manager who was also the provider for the service. The registered manager was supported by a care manager to run the service. We refer the registered manager as the manager in the body of this report.

The service was last inspected on 30 September 2015 when we found the provider was not meeting the required standards. We identified two breaches in the legal requirements and regulations associated with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider to improve their staffing arrangements and ensure that risks were assessed and monitored relating to the health, safety and welfare of people who used the service.

The provider sent us an action plan which stated all the required improvements would be completed by 1 April 2016. During this inspection we checked whether the improvements had been made. We found not all improvements had been made and sufficient action had not been taken in response to the breaches in regulations.

The provider had not ensured that effective quality assurance procedures were in place to assess and monitor the quality and safety of the service people received. Risk assessments were in place to manage the risks associated with people’s safety, health and well-being. However, audits and checks were not always effective to identify where people’s needs had changed. Therefore, we could not be sure people were kept as safe as possible. People’s care records were not always personalised to give staff guidance on how people preferred their care and support to be provided.

People’s experiences of being supported by consistent staff were mixed. People told us there were not always enough care staff to meet their needs because staff did not always arrive at the agreed times. We identified the deployment of staff had not been sufficiently improved since our previous inspection to meet people's need to care for them.

We received mixed feedback from people about how the service was run because a manager was not always available when they needed them, and they did not feel their requests were always listened to and acted upon promptly.

Staff completed training to meet people’s needs but we identified not all of the training was effective. Despite the provider taking some action since our last inspection medicine administration records required further improvement, because records were not completed correctly. This meant we could not be sure people received their medicines as prescribed.

The provider’s recruitment procedures made sure staff were of suitable character to care for people in their own homes. Staff completed an induction when they first started work at Bella Home Care. They completed training and knew how to raise concerns and safeguard people from potential harm. Most people thought staff had the skills and knowledge they needed to provide the care and support they required.

People told us they felt safe with the staff who supported them and the staff were kind and attentive to the

This inspection took place on 30 September 2015. The inspection was announced. We gave the provider two days’ notice of our inspection. This was to make sure we could meet with the manager of the service on the day of our inspection visit.

Bella Home Care is registered to provide personal care and support to people living in their own homes. The service operates across Southam, Leamington Spa, Warwick and Kenilworth. There were 120 people using the service at the time of our inspection.

A requirement of the provider’s registration is that they have 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. At the time of our inspection there was a registered manager who was also the provider of the service. We refer to the registered manager as the manager in the body of this report.

We found there were not enough staff at Bella Home Care to support people in accordance with their needs and preferences. In addition staff had not previously been allocated travel time between calls. This had resulted in late calls, and staff not always staying for an agreed period of time. However, the provider was acting to improve the times staff arrived and left people’s homes by incorporating travelling time into rotas. The provider was also recruiting more staff, and extra staff were being allocated to rotas to allow for staff absences.

We found that care records were not always up to date, and risk management plans were not always in place to manage the risks associated with people's health and wellbeing.

People told us they received their medicines as prescribed, however, medicine records needed to be improved to ensure staff had the information they needed to administer medicines to people safely.

There were systems in place to monitor the quality of the service. This was through feedback from people who used the service, their relative’s, and audits. Audit procedures did not always identify areas where improvements needed to be made. The provider did not always utilise monitoring and auditing systems that were available to them, to monitor staff performance.

People and their relatives told us they felt safe with staff. The manager and staff understood how to protect people they supported from abuse, and knew what procedures to follow to report any concerns. The provider had recruitment procedures that made sure staff were of a suitable character to care for people in their own homes.

People were supported to attend appointments with health care professionals when they needed to, and received healthcare to maintain their wellbeing.

People and their relatives thought staff were kind and responsive to people’s needs, and people’s privacy and dignity was respected.

Management and staff understood the principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and supported people in line with these principles. People who lacked capacity to make all of their own decisions did not always have a current mental capacity assessment in place. This meant records did not consistently show which decisions people could make for themselves, and which decisions needed to be made on their behalf in their ‘best interests.’ The provider was implementing a new format of care records at the time of our inspection to address this. Staff we spoke with knew people well and could explain when people could make their own decisions, and when people needed support to do so.

Activities, interests and hobbies were arranged according to people’s personal preferences, and according to their individual care packages. All of the people and their relatives had arranged their own care packages. They had agreed with Bella Home Care how they wanted to be supported. People were able to make everyday decisions themselves, which helped them to maintain their independence.

Staff were supported by the manager through regular meetings. There was an ‘out of hours’ on call system in operation to provide management support and advice to staff at all times. Staff felt their training and induction supported them to meet the needs of people they cared for. Training was monitored and staff were required to keep their training up to date. Where issues had been identified regarding the effectiveness of training, staff were asked to undergo refresher training to enhance their knowledge.

People knew how to make a complaint if they needed to. The provider investigated and monitored complaints, and made changes to the service where required improvements were identified.

We visited Bella Homecare on 20 August 2013. During our visit we looked at how information had been recorded in people’s care plans. We found the provider had not recorded important information about people. For example health conditions to ensure people’s care and welfare was protected. We found information was not up to date to ensure care workers had correct information to care for people safely.

Care staff knew people well and people who used the service told us they had no concerns about their care and they received very good quality care.

We met with the provider on 5 September 2013 to discuss the actions we required them to make. They agreed to review all their care plans by the 8 November 2013.

We visited Bella Homecare on 29 November 2013. We reviewed three care plans and found the provider had carried out a full review of people's care.

We last inspected the service on 8 January 2013. We found the provider had not protected people from unsafe or inappropriate care because accurate and appropriate records had not been maintained and records were not held securely.

In February 2013, at our request, the provider sent us an action plan telling us how they were going to improve. They told us they would be compliant by 7 April 2013.

When we visited on 20 August 2013 we found the provider had made improvements to the records of the care worker files but had not made improvements to the care records of people who used the service.

During our visit we spoke with the manager, deputy manager, compliance manager, care manager, four care staff.

We spoke with two relatives and 19 people who received a service from Bella Home Care to obtain their views.

People and their representatives said they were happy with the care provided. We saw the care plans held at the office. These did not always contain important information about people the service looked after.

Comments from people received included “I am happy, otherwise I would not use them” and one relative said "They look after X well."

People told us they felt their relative was safe and would make a complaint if it was

necessary.

Staff told us they had meetings with the manager, but that these were not always documented. They told us they had received mandatory training.

The agency had some quality checks in place to ensure they provided a good service.

We spoke with two people using the service and one relative. We also spoke with the manager, the care coordinator and three care workers.

Systems were in place allowing people and their relatives to communicate their experiences. The manager said that the last ‘service user satisfaction survey’ had taken place in April 2012. People told us that they felt able to express their views and felt confident when doing so. Some comments made by people were: ‘’There is a feedback reporting process in place’’ and ‘’ We verbally fed back that we were pleased with the care.’’

We saw people's needs had been assessed, risks identified and personalised support plans developed. Two people's records confirmed that reviews of care plans and risk assessments had taken place. We found some gaps in two people’s records as the information had not been collected and written down. This could put the person at risk if a person’s records are not complete.

Staff confirmed that recruitment processes were robust. The provider may like to note that we saw there had been some shortfalls in their recruitment practice. The care workers said they felt supported by the manager and their team. They said they had received appropriate training and development and confirmed a system of supervision and appraisal was in place. We were told of the staffing contingency plans which were in place.