This inspection took place on 7 and 16 June 2017 and was announced. Care-Nursing Alliance Recruitment provides domiciliary care services to a range of people who live in their own home. The service often provides complex care including 24 hour care or care contracted through continuing healthcare. At the time of our inspection there were 14 people with a variety of care needs, including older people, people living with physical disabilities and children.

We last inspected on the 4 and 5 December 2014. At the December 2014 inspection the service was meeting all of the requirements of the regulations and was rated as “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 and their relatives spoke extremely positive about the outstanding care they or their relatives received. The service often went above and beyond their contractual obligations to ensure people had a good quality of care. People were placed at the centre of their care and were supported to develop their independence, meet their individual desires and live their lives to the fullest.

People and their relatives were heavily involved in their care and spoke extremely positively about the professional relationships they had with all staff employed by the provider. The registered manager contracted healthcare professional support and guidance at the provider’s cost to ensure care staff had clear and comprehensive guidance to provide high quality person centred care in accordance with people’s needs. The service had strong links with healthcare professionals and all healthcare professionals spoke highly about the quality of care people received.

People were cared for by committed care staff who were supported by a dedicated management team including care co-ordinators, registered manager and provider. People’s relatives were involved in providing training to care staff which enabled them to provide exceptional person centred care. Relatives spoke positively about the support they received to provide this training.

There was a strong structure of leadership within the service. Staff were supported to professionally develop and be responsible for additional duties. Staff felt valued by the service. The registered manager and provider knew the needs of staff and had systems to ensure staff had access to the training and support they needed.

Staff and other professionals spoke very highly of the registered manager and gave positive feedback about their approach to caring for people. The service was passionate about providing high quality person centred care for people. All staff understood the providers and registered managers caring values.

In this report the name of the registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time of this inspection. We have advised the provider of what they need to do to remove the individual’s name from our register.

At our last inspection in June 2013, we found the provider to be non-compliance in four outcomes. We took enforcement action and told the provider to become compliant by 30 September 2013. This visit was to check the provider had taken appropriate action for each of the four outcomes.

During this inspection looked at the care files for 11 people who used the service. We spoke to three people who used the service. We spoke to six relatives of people who used the service and spoke to 14 members of staff. We found that the care files had been brought up to date with accurate care plans and risk assessments. Six monthly reviews had started and feedback had been obtained from people who used the service. We noted that the provider had made significant improvements since our last visit and had achieved compliance in all four outcomes.

We had received concerns from staff relating to different aspects of the care people received as well as how the provider supported staff. The provider was over due an inspection and we therefore brought forward our planned inspection. We were informed by the manager that they had been in post for six days prior to our inspection. During those six days, the manager had started a full service review and an action plan for any issues that had been identified. The issues the manager had identified reflected what we found during our inspection and this gave us confidence that the new manager understood what needed to be done to resolve them quickly.

We found a lack of care plans and risk assessments in place. Not all staff had received safeguarding training. No quality monitoring system appeared to be in place. Staff were not protected from the risk of violence in peoples homes and the provider's recruitment processes were not robust. Having said that, the comments from people in the yearly satisfaction survey was mainly positive about the care they received and the staff. We saw no evidence that suggests people are receiving poor care from the staff.

Care-Nursing Alliance provides domiciliary care services to people who live in their own homes, in the Gloucestershire area. At the time of this inspection 21 people, children or younger adults were receiving personal care support from the service. Throughout the report we have always referred to the people, younger adults and children who were receiving support as ‘people’.

There is a condition of registration that the regulated activity of personal care is managed by an individual who is registered with CQC as a manager. A registered manager has the legal responsibility for meeting the requirements of the law; as does the provider. There was a manager in post but the process of registering them had not been completed at the time of the inspection.

People told us they felt safe whilst they were being looked after and supported by care staff. One person said that the staff used hoisting equipment properly and always used the equipment in the same way. People were protected from being harmed because risk assessments and management plans were in place to reduce or eliminate the risk. In order to safeguard people from being looked after by unsuitable staff robust recruitment procedures were followed and all staff received safeguarding training to ensure they were familiar with safeguarding issues.

People received the service they expected from care staff who had the skills and knowledge to meet their specific care and support needs. All staff received a range of training (moving and handling, safe medicine administration, health & safety, for example) but other ‘person specific training’ was provided to enable care staff to undertake their roles effectively when looking after people with complex care needs.

People were asked to consent to care and support before a service was delivered. A person’s ability to give consent was assessed as part of the overall assessment process and where decisions needed to be made by others, best interest meetings were held with all other relevant parties. Where children were being supported, consent was provided by the parents or guardians.

Where required people were supported to eat and drink. People were supported to access health care services if needed.

People said they had good working relationships with the care staff who were supporting them and also the office based staff. They said they were treated with kindness and respect. People were involved in the assessment process and had a say about how their care needs were to be met.

Their preferences and choices were respected and they were provided with copies of their plans and staff duty sheets so they knew who was to support them.

People said the service was well-led and they were encouraged to provide feedback. The quality and safety of the service was regularly monitored and used to make improvements. The service had a clear vision of where improvements were required.