The inspection took place on 11 May 2018 and was announced. We also contacted staff and people using the service and their relatives following the site visit. The service was last inspected in 2015 and was not in breach of the regulations at that time. Burgundy Care Services Limited is a domiciliary care agency. It provides personal care to people living in their own homes in the community. Not everyone using Burgundy Care Services Limited receives 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. At the time of this inspection they supported 70 people in their own homes, 23 of whom received personal care.

There was a registered manager in post who had been registered since the company started in 2011. 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.

Staff had received training in safeguarding adults and children. They demonstrated a good understanding of how to recognise abuse and ensure people were safeguarded.

Risk assessments were in place in relation to the environment and for people using the service. Not all risks had been assessed to enable management plans to be developed which would provide guidance for staff to follow to keep people safe from harm.

Accidents and incidents, although infrequent, were recorded on the electronic system.

Recruitment practices were on the whole in line with best practice but some improvements were required.

The management of medicines did not follow current best practice. There was no written record of the medicine support given to a person for each individual medicine on every occasion, to provide a clear record of all medicines administered or applied.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; Staff were able to describe how they would support people to make decisions if they lacked capacity and how they would act in their best interests when providing care.

People who used the service and their relatives spoke highly about staff and told us they were caring. They said staff were respectful at all times and ensured their privacy was maintained. Staff had time to sit and chat and people did not feel rushed during their care and support.

Care plans were not recorded in a person-centred way to enable an understanding of the person’s personal history, individual preferences, interests and aspirations. They lacked information about the person’s strengths, levels of independence and quality of life.

Complaints were recorded on their electronic system but these were not compiled to show how the service had analysed and responded to information gathered or used this information to make improvements to the service.

There was a lack of systems and processed including regular audits which meant the registered provider was unable to identify where quality and safety needed to improve. Up to date nationally recognised guidance had not been embedded in policies nor implemented by the registered manager.

There was no satisfaction survey completed to compile and analyse the information gained about the service which would have demonstrated how they were acting on the views of people using the service and professionals to drive improvements.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment and good governance. You can see what action we told the provider to take at the back of the full version of the report.

This inspection took place on 6 August 2015 and was announced. The registered provider was given 48 hours’ notice because the location provides a domiciliary care service; we needed to be sure the manager would be available to meet with us.

Burgundy Care and Support Services was set up in 2011 and providesOn the day of our inspection 37 people were receiving support with personal care.

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.

Staff and the management team had received training in safeguarding vulnerable adults and all the staff we spoke with were able to describe what actions they would take if they suspected abuse to ensure the people they supported were safe from harm

The service had a general risk assessment tool which covered potential risk at the property, personal safety of staff, household equipment, physical assistance to transfer or mobilise, personal care tasks, and medication. Risks were managed and reduced although there was a lack of detail around some areas of risk such as specific risk assessments around bathing.

The service enabled staff to access training to ensure the staff had the knowledge and skills to perform in their role. Staff told us they were encouraged to increase their knowledge and skills by taking advantage of the training on offer.

Staff had received training in the Mental Capacity Act 2005. Staff sought consent from people in line with legislation and supported people who lacked capacity to make decisions about their care.

People who used the service and their relatives told us staff were caring. They told us staff did not rush them and they had time to chat. They told us the staff were respectful at all times and ensured their privacy was maintained.

People received care that met their needs, choices and preferences and they were involved in the review of their service.

People knew who to complain to and had every confidence that any concerns would be acted on and resolved.

Staff enjoyed working at the service and had great pride in their work. They felt confident in and supported by the management and the culture of the organisation was good.

Certain aspects of the service such as time spent with people, and missed calls was constantly monitored by the registered manager but there was a lack of documented audits of the quality or the safety of the services provided to the people who used the service. This meant the service could not easily demonstrate the quality of the service they were providing even though all the people who we spoke with and professionals spoke highly of the service provided.

The service had also not always met their regulatory requirements by sending notifications to the Care Quality Commission relating to a safeguarding although they had managed the risks and referred to the local authority as required. They had not provided the Commission with a Provider Information Return (PIR) as had deleted the email from the CQC believing it to be spam.

When we visited the service in May 2013 we found there were issues regarding staff not receiving training in safeguarding, effective recruitment processes were not in place and there were also issues relating to the way the service carried out record keeping. When we returned to the location we found they had provided staff with safeguarding training, renewed records in relation to recruitment and ensured that records were now kept in accordance with recommended guidelines.

We spoke with three people who used the service and a relative of another person who used the service. The relative of one person told us "I have no issues at all, I'm very happy. Mum gets on well with the carers". One of the people who used the service told us "It's a very good service, the girls are all very nice". We were also told "They deliver everything in my careplan, they always have time to chat". Another person who started using the service following a hospital admission told us "I thinks it's ok. I've had some problems. I have a list of things that need to be done, sometimes things get missed".