This inspection took place on 21 November 2018 and was announced. We gave the provider short notice before our visit to ensure the registered manager was available. This was the first inspection of this service since it was registered with the Care Quality Commission (CQC). This service is a domiciliary care agency. It provides personal care to people living in their own homes. At the time of our inspection three people were using the service. The registered manager was also the provider. There were two staff who provided the care one of which was the registered manager.

There was a registered manager in post who is registered with us. 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 felt safe with the staff that supported them but systems were not in place to ensure staff had the skills and knowledge to protect people’s rights and keep them safe. People were not always protected because management plans were not in place to manage risks based on people’s individual assessed care needs but were reliant on staff knowing people well.

People were supported with their medication when required however staff had not received training to ensure people received their medication safely.

There were sufficient numbers of available staff to care for people who had been recruited following appropriate checks. Training and supervision was not always completed to ensure staff had the skills and knowledge to care for people

People were consulted about their care so their wishes, choices and preferences were known so they could receive care that met their individual needs. People could make decisions about their care and were actively involved in how their care was planned and delivered.

The registered manager had not completed training in the Mental Capacity Act MCA to ensure people’s rights to make decisions were promoted and understood by the staff. People’s privacy and dignity was promoted and maintained.

People said they would complain if they were unhappy but were not sure of the procedure. Staff supported people with their nutrition and health care needs. Referrals were made in consultation with people who used the service if there were concerns about their health.

The registered manager had some systems and processes in place to monitor the quality and safety of the service. However, some of these were not always implemented effectively to ensure information gathered was used to drive improvements within the service. The registered managers quality assurance practices had failed to identify the shortfalls that we found during our inspection and had the potential to compromise the safety and quality of the service. Therefore, this was a breach of Regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014. You can see what action we have taken at the end of the report.