This inspection took place on the 12 and 18 June 2018 and was announced.

At our last comprehensive inspection in June 2017 we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued the provider with one requirement notice and one warning notice, stating they must take action.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We undertook an announced focused inspection of C&S Makenston Special Care Service on 30 November 2017. This inspection was done to check that improvements to meet legal requirements planned by the provider after our comprehensive inspection in June 2017 had been made. The team inspected the service against two of the five questions we ask about services: is the service safe and is the service well led. This is because the service was not meeting some legal requirements.

No risks, concerns or significant improvement were identified in the remaining Key Questions through our on-going monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

During this inspection we found the provider had not sustained the improvements made. Following this inspection we wrote to the provider to ask them what immediate action they would take to make the necessary improvements to meet the legal requirements. The provider sent us an action plan stating what action they were taking and by what date the action would be completed. They had also contacted the local authority quality assurance team to support them with making improvements.

This is the third consecutive time the service has been rated Requires Improvement.

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community. It provides a service to older adults and younger disabled adults. At time of our inspection six people were using this service.

The service is registered as an individual provider which means it does not require a registered manager to be in post at the service. The individual provider is responsible for the day to day running of the location, and has the legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated regulations about how the service is run.

Recruitment at the service continued to be unsafe.

Medicines were not always managed safely and we found gaps in the medicines administration records (MAR’s). Staff did not sign their name when they prompted people with their medicines, which meant there wasn’t an audit trail of who had administered the medicines. The manager audited the MAR’s, however did not identify the shortfalls we identified during this inspection.

The manager and staff demonstrated a lack of understanding of the Mental Capacity Act (2005) and Deprivation of Liberty safeguards.

We have made a recommendation that the provider seek guidance regarding the MCA (2005).

Staff had not been supported to receive necessary training relevant to their role before they started providing care to people. This meant people were receiving care from staff that were not appropriately trained which potentially put them at risk of unsafe practice.

Risk assessments did not contain enough detail to provide guidance to staff to minimise the risk to people’s safety.

Staff occasionally provided nursing tasks, which was not within their remit. There was no evidence to show that the provider had discussed this with the community nursing team to delegate these tasks.

Care plans were not always person centred. Where people had a specific health need there was not always clear information in place and documents were not always completed appropriately. There was no end of life wishes documented in people's care plans.

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At the comprehensive inspection of this service in June 2017 we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued the provider with a Warning Notice. This was because staff had not been thoroughly checked before they started work at the service to ensure they were safe to work with people. We also issued a requirement notice for one breach, stating they must take action. This was because the service did not have suitable systems in place to identify areas that needed to be improved and take action to resolve them.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to the questions Is the service safe? And Is the service well-led?. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for C&S Makenston Special Care Service on our website at www.cqc.org.uk

We undertook an announced focused inspection of C&S Makenston Special Care Service on 30 November 2017. This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats. It provides a service to older adults and younger disabled adults in Trowbridge and the surrounding area. At the time of our inspection three people were receiving personal care from the service.

This was an announced inspection which meant the provider knew two days before we would be visiting. This was because the location provides a home care service. We wanted to make sure the provider, or someone who could act on their behalf, would be available to support our inspection.

The provider is an individual and is in day to day charge of the service. The service does not have a condition of registration that they must have a registered manager.

The provider had taken the immediate action necessary needed to keep people safe following the last inspection. However, further action was needed to complete the actions that had been started and to ensure the improvements were sustained.

The provider had made applications to the Disclosure and Barring Service (DBS) for all care staff who did not have one at the time of the last inspection. A DBS disclosure gives an employer details of any convictions or cautions an applicant may have and whether the person is barred from working with vulnerable adults. The provider was waiting for these disclosures to be returned from the DBS, but had obtained declarations from staff regarding any convictions or cautions and had copies of DBS disclosures issued for staff from previous employment.

Since the last inspection, the provider had obtained a full employment history for all care staff, including a written explanation for any gaps in employment. Where staff had a previous conviction, the provider had completed a risk assessment, setting out their reasons for assessing that it was safe for these staff to work with people in this care setting.

The provider had developed action plans to address the shortfalls that had been identified at the last inspection, which had led to improvements in recruitment checks on staff. The provider had other quality assurance systems in place, which they used to receive feedback about the way the service was operating. However, work was needed to ensure these systems were formalised and would continue to be effective as the service grew to provide care for more people.

People who use the service were positive about the care they received and praised the quality of the staff and management. Comments included, “I’m very happy with the care, the girls are excellent. They know what they’re doing and do it very well.”

People told us they felt safe when receiving care and were involved in developing and reviewing their care. Systems were in place to protect people from abuse and harm and staff knew how to use them. Staff understood the needs of the pe

C&S Makenston Special Care Service provides a care at home service for adults in Trowbridge and the surrounding area. At the time of our inspection six people were receiving personal care from the service. The service was last inspected in July 2016 and required improvement.

This inspection took place on 21 and 26 June 2017. This was an announced inspection which meant the provider knew two days before we would be visiting. This was because the location provides a home care service. We wanted to make sure the provider, or someone who could act on their behalf, would be available to support our inspection.

The provider is an individual and is in day to day charge of the service. The service does not have a condition of registration that they must have a registered manager.

The provider had not taken all the action we said they needed to after the last inspection. Staff employed by the provider had not been thoroughly checked before they started providing care to people. The provider did not have current information about any convictions or cautions staff may have or satisfactory assurance about their performance in other care work. The provider did not have all the information they needed to be able to make a decision about the suitability of staff to work alone with people.

The provider had improved their quality assurance systems since the last inspection. However, they had not identified that their recruitment checks on new staff were not suitable and did not meet the requirements of the regulations.

The provider had taken action to meet the other regulations they were in breach of at the last inspection in July 2016.

People who use the service were positive about the care they received and praised the quality of the staff and management. Comments included, “Excellent care. I don’t have a bad word to say about them. They’re fantastic”, “They’re lovely and friendly” and “They will do what I want them to do. I have no concerns at all”.

People told us they felt safe when receiving care and were involved in developing and reviewing their care plans. Systems were in place to protect people from abuse and harm and staff knew how to use them.

Staff understood the needs of the people they were providing care for. Staff were appropriately trained and skilled and demonstrated a good understanding of their role and responsibilities. Staff had completed training to ensure the care and support provided to people was effective.

The service was responsive to people’s needs and wishes. People had regular meetings to provide feedback about their care and there was an effective complaints procedure. People felt they could contact the provider if needed and were confident action would be taken.

We found continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see details of the action we took in the main section of this report.

C&S Makenston Special Care Service provides domiciliary care and support services to people with individual needs in their own homes. At the time of our inspection four people were being supported.

This inspection took place on 8 July 2016. This was an announced inspection which meant the provider had prior knowledge that we would be visiting the service. This was because the location provides a domiciliary care service, and we wanted to make sure the manager, or someone who could act on their behalf, would be available to support our inspection. This was the provider’s first inspection since they registered with CQC in 2014.

The service is registered as an individual provider which means it does not require a registered manager to be in post at the service. The individual provider is responsible for the day to day running of the location, and has the legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and

associated regulations about how the service is run.

The service did not follow the requirements set out in the Mental Capacity Act 2005 when people lacked the ability to give consent to their care within their own home. This meant it was not possible to say whether these people consented to the care and treatment they were receiving, or if they did not have capacity to consent to their care.

Staff had not received the appropriate training relevant to their role. We identified gaps in the training records. Where staff had received training some of this had been completed but dated as far back as 2004. This meant training had been from their previous employer and they had not received training relevant to their role since being registered with CQC in 2014.

Medicines were not managed safely and where people were self-administering medicines, associated risk assessments were not in place. Medicines administration records (MAR charts) were not completed.

Care plans did not provide enough information about a person, their health condition and care needs. Risks to people were not fully documented and action plans had not been put in place for staff to follow.

The service did not follow safe recruitment practices. The staff files we looked at did not have the relevant references and ID checks needed.

The manager of the service worked as part of the care team on a daily basis but this left little time for managerial duties. The service did not have fully effective systems in place to evaluate and improve the quality of the service.

Staff were aware of the types of abuse people may be at risk of and the actions to take if they suspected someone was at risk of harm. Staff were aware of their responsibility to report any concerns they had about people’s safety and welfare. However, the manager had not notified CQC about significant events, such alleged abuse.

People's health care needs were monitored and any changes in their health or well-being prompted a referral to their GP or other health care professionals.

We found breaches of the regulations. You can see what action we told the provider to take at the back of the full version of the report.