This comprehensive inspection took place on 31 July 2017 and was announced. We gave the registered manager two working days’ notice as the location provided a service to people in their own homes and we needed to confirm the registered manager would be available when we inspected.

The last inspection took place on 14 June 2016, when we identified breaches of Regulations relating to safe care and treatment, the need for consent, fit and proper persons employed, staffing and good governance. We rated the service ‘Requires Improvement’ in three of the key questions we ask providers and overall. During the 31 July 2017 inspection, we saw improvements to the service had been made.

The Dominion Centre, also known as The Ashra Project, was part of a larger organisation called The Asian Health Agency (TAHA) that provided support to people from the Asian community. We inspected the Dominion Centre part of the service that provided support to people in their own homes. At the time of the inspection, 21 people used the Dominion Centre but only three people received support that came under the Care Quality Commission regulations because they were receiving the regulated activity of personal care.

The service had 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 inspection on 31July 2017, we saw that people were involved in their care plans. However, they did not provide enough person centred information and we have recommended care plans were reviewed to provide more information about people’s needs and to reflect their personal preferences in more detail.

The service had a medicines policy and procedures and medicines were administered safely. However at the time of the inspection, the registered manager said although they were completing monthly Medicines Administration Records (MAR) audits for the two people using MAR charts, they did not keep a written record of the audit but would do so in the future.

Care workers received safeguarding adults training and those we spoke with knew how to respond to keep people safe from potential harm. Risk assessments had been reviewed and updated.

People using the service and their relatives said they were happy with the care provided. There were sufficient numbers of staff who consistently supported the same people and were aware of individual needs.

Care workers had the relevant training and support through supervisions and appraisals to develop the necessary skills to support people using the service. Safe recruitment procedures had been followed to ensure suitable staff were employed.

People were supported to have maximum choice and control of their lives and care workers were responsive to individual needs and preferences. People using the service had developed positive relationships with care workers and said care workers were kind and caring.

People’s dietary requirements were met. People lived with their families who often managed healthcare needs but the service could support people to appointments and knew how to alert the emergency services if needed.

People and care workers said the registered manager was accessible and approachable. People using the service knew how to complain but there had been no complaints to the service.

The registered manager had good links with the community and was aware of their responsibility of when to notify relevant bodies including the Care Quality Commission of some events and incidents within the service.

The provider had management systems in place to monitor the quality of the service and reduce risks to people using the service.

The inspection took place on 14 June 2016 and was announced. We gave the registered manager two working days’ notice as the location provided a service to people in their own homes and we needed to confirm the registered manager would be available when we inspected.

The last inspection took place on 04 September 2013 at which time the service was compliant with the regulations we checked.

The Dominion Centre was part of a larger organisation called The Asian Health Agency (TAHA) that provided various types of support to people from the Asian community. We inspected a part of the service called the Ashra Project that provided support to people in their own homes. At the time of the inspection, 10 people used the Ashra Project but only two people received support that came under the Care Quality Commission regulations because they were receiving the regulated activity of personal care.

The service had a registered manger. 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.

We saw that the service was not always safe. People did not have individual risk assessments to identify and manage risk.

There were not always two employment references or up to date Disclosure and Barring Service (DBS) checks which meant people who used the service were not always protected.

The service had not always assessed people’s capacity to consent to care and treatment and we saw a care plan where a family member had signed on behalf of the person using the service although there was no indication that the person was unable to sign the care plan for themselves.

Care workers were administering medicines but there was no record of medicine training recorded in the files. The service did not use Medicine Administration Records (MAR) charts, which meant medicine administration was not being recorded in line with relevant guidance.

The service was not undertaking staff appraisals to promote staff development and best practice. This meant the service lacked a formal mechanism for setting staff targets for the year and monitoring the outcomes.

Relevant training such as medicines management and Mental Capacity Act 2005 training were not up to date.

The service was not always well led because it lacked systems to monitor the quality of the service delivered and ensure peoples’ needs were being met.

The service had policies for safeguarding people who used the service and care workers were aware of how to respond to safeguarding concerns.

There were an adequate number of staff to meet the needs of the people who used the service.

People who used the service and their families were happy with the level of support they received.

The service was very flexible and accommodated requested changes people made.

The registered manager was accessible.

There was a complaints system and people felt able to raise concerns.

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

At the time of our inspection there were two people receiving support with personal care from the service. We were unable to speak with people using the service as they had complex needs which prevented them from sharing their experiences with us. However, we were able to speak to a relative, two care staff and the manager of the service and we looked at records to gain information about people's experiences.

People and/or their representatives were asked for their consent prior to care being provided and staff were able to demonstrate how they involved people in decision making. We found that people's needs were assessed prior to care provision and a care plan developed outlining the action staff should take to meet these. However, care plans did not always contain personal information important to the individual in relation to their likes, dislikes and preferences.

The relative we spoke with told us that staff provided "consistent care and attention" and said, "they (staff) are flexible and we have a relationship with them."

Staff checks were undertaken before they commenced working for the agency to ensure they were suitable to work with vulnerable adults.

Staff received appropriate support and training to equip them with the skills and knowledge to meet people's needs effectively.

The manager of the service monitored the quality of care provided to ensure that people's needs were met and changes made where areas for development were identified.

There were 32 people using the service at the time of the inspection. We spoke with four people, the manager of the service and two other members of staff. People told us their care needs were discussed with them or a family member before they received a service from the agency. We also saw that regular feedback was sought from people about their experiences of the service.

People told us that staff treated them respectfully. One person said, "I like our carer, she is polite and respectful, we get along". We saw that people's needs had been assessed and a care plan developed to enable staff to effectively meet them. Risks to people's welfare had been considered when developing their care plans. However, not all identified risks had been assessed to ensure that staff took the appropriate action to keep themselves and the people using the service safe.

There were appropriate systems in place to protect people from the risk of abuse and people told us they felt safe when being cared for by staff. People were made aware of how to complain if they were unhappy about the service they were receiving and complaints were responded to promptly and appropriately.

People were not protected from unsuitable workers as the recruitment checks that were taking place were not thorough and not all of the required information was obtained prior to people starting work.