We carried out an announced inspection of Grade A Care on 26 June 2018. The provider was given 48 hours' notice of the inspection because the location is a small, family run domiciliary care service and we needed to be sure someone would be available to facilitate the inspection.

Grade A is a domiciliary care agency in Hindley, Wigan. It provides personal care to people living in their own houses and flats in the community. Not everyone using Grade A receives a regulated activity; the Care Quality Commission (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 consider any wider social care provided.

At the time of inspection, there were seven people receiving a regulated activity from the service.

The service was last inspected in June 2017, when we identified a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in regard to regulation 17; good governance. We also made three recommendations in relation to risk assessment documentation, training and reviewing people's care needs within specified time frames.

Following this inspection, the service was rated as requires improvement overall and in the key lines of enquiry (KLOE's); responsive and well-led. The service was rated as good in safe, effective and caring.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions; responsive and well-led to at least good. However, the provider failed to submit the requested action plan.

We reviewed the progress the provider had made as part of this inspection and found the provider remained in breach of regulation 17; good governance (two parts). We also identified an additional breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in regard to regulation 18; staffing. We also made a further recommendation to review risk assessment documentation. You can see what action we told the provider to take at the end of the full version of this report.

This was our third inspection of Grade A where the rating has not improved from requires improvement. All previous inspection reports can be viewed by clicking the ‘all reports’ button on our website at www.cqc.org.uk. We are currently considering our options in response to this third requires improvement rating in line with our methodology.

At the time of the inspection 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 we spoke with told us they felt comfortable with the staff and had no safety concerns.

At our last inspection we recommended the service sought advice and guidance from a reputable source regarding individual risk assessment documentation. This was because the risk assessments in place did not identify sufficient control measures to mitigate all risks and were not kept under review. At this inspection we found this had not been actioned and the risk assessment documentation was unchanged.

There was a recruitment process in place, but records to demonstrate this had been followed were not sufficiently maintained.

People continued to be supported by staff who understood their responsibilities if they suspected people receiving support from the agency had been abused or mistreated.. Staff were also knowledgeable about how to report accidents and incidents.

Medicines were managed in a safe way with records being completed accurately and all medicines given as prescribed.

There were sufficient staff employed to meet current care commitments and missed visits were not a concer

This inspection took place on 08 June 2017 and was announced. The provider was given 48 hours’ notice of the inspection because the location provides a domiciliary care service and we needed to be sure someone would be in the office to facilitate the inspection.

At our inspection in December 2015, we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches were in regards to the following regulations; safe care and treatment, good governance (two-parts) and staffing.

The service was rated as good in caring and requires improvement in all the other key lines of enquiry (KLOE’s) which meant the service was rated as requires improvement overall.

At this inspection we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in regards to regulation 17; good governance. You can see what we told the provider to do about it at the end of this report.

We also made three recommendations in relation to risk assessment documentation, training and reviewing people’s care needs within specified time frames.

Grade A is a small family run domiciliary care agency in Hindley, Wigan. The agency provides care and support to people who live in their own home who have a variety of care needs. At the time of our inspection there were 14 people using the service.

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.

All the people and relatives of people receiving support told us they had no concerns regarding people’s safety as a result of the care provided.

We saw the service had suitable safeguarding policies and procedures in place. Staff had received training in safeguarding vulnerable adults and demonstrated a good understanding of how to report both safeguarding and whistleblowing concerns

Recruitment checks were carried out to ensure staff were of suitable character to work with vulnerable people. We saw there were sufficient numbers of staff employed by the service to meet people's needs and the registered manager told us staffing levels were sufficient to meet the current care packages.

We recommended the service sought advice and guidance from a reputable source regarding individual risk assessment documentation. This was because the risk assessments in place did not identify sufficient control measures to mitigate all the risks.

People and their relatives confirmed there were not frequent missed visits and when staff were running late due to unforeseen circumstances, people were contacted by phone and given an explanation.

Medicines continued to be managed safely and administration procedures were followed correctly by staff.

A robust induction programme such as the 'care certificate' had not been implemented at the service but all current staff had enrolled on NVQ’s and had previous care experience and relevant qualifications.

People's rights under the Mental Capacity Act 2005 (MCA) were protected. Care staff supported people to have maximum choice and control of their lives in the least restrictive way possible; company policies and procedures supported this practice. Care records showed people were involved in their care and support.

People were supported by a small staff team which promoted continuity of care and people and their relatives spoke positively of the care provided and the relationships that had developed.

Care plans were in place to guide staff about how best to support people, but were not personalised to take in to account people's equality and diversity needs. However, we found staff demonstrated that they knew people's likes, dislikes, preferences, routines and arrangements were in

The inspection took place on 04 December 2015 and was announced. 72 hours’ notice of the inspection was given so that the manager would be available at the office to facilitate our inspection. Grade A provides domiciliary care services to people who live in their own home. At the time of our inspection there were six people using the service, with a variety of care needs, including people living with dementia.

The service was last inspected on 16 September 2013 and at the time was meeting all the regulations assessed.

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.

During this inspection we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.These were in relation to; Safe Care and Treatment, Good Governance and Staffing. You can see what action we told the provider to take at the back of the full version of this report.

We found the registered manager was unable to demonstrate how they captured, reviewed and monitored any trends or patterns for accidents and incidents or shared information about them with the care workers to prevent re-occurrence and to promote learning. This was a breach of 12(2)(b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 .

People told us they felt safe and relatives had no concerns regarding their family member’s safety. Care workers understood the need to protect people from harm and abuse and knew what action they should take if they had concerns.

People were complimentary about the care and support they received. People spoke highly about the care workers and valued having care workers who were consistent and with whom they had built relationships. People and their relatives spoke positively about the skills of the care workers and felt they were efficient and well trained.

We saw employment checks had been conducted prior to care workers commencing with the agency and current staffing levels were sufficient to meet the care packages. People had not experienced missed visits and when visits were late people were contacted and given a reason.

Care workers received an induction and shadowed experienced care workers until they felt confident to provide care independently. We saw care workers undertook mandatory training but there were shortfalls in the training as it did not cover specialist topics which were required to enable care workers to fulfil the requirements of their role. This is a breach of Regulation 18 (2) (a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 with regards to Staffing.

People were looked after by care workers that were kind and caring and promoted people’s privacy and dignity. Despite not receiving MCA training, people’s rights in making decisions and suggestions in relation to their support and care was valued and acted upon. People and their relatives were involved in the initial assessment process to ascertain people’s needs and how they wanted care to be provided.

We found care plans were not person-centred and did not identify people’s individual goals as specified in the agencies policy. The care plans were prescriptive detailing how care was to be delivered and did not incorporate individualized, measurable and achievable goals. We made a recommendation about person centred care planning.

During the inspection, the registered manager was unable to find the policies and procedures in the office. The computer advisor was a volunteer at the agency and accessed these on-line and printed copies during our visit. We found the policies did not reflect the current regulations and lacked detail to guide staff on what procedure to follow when met with certain circumstances. This was a breach 17(2)(d) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

The registered manager had no formal auditing process to ensure they consistently ensured the delivery of high quality care. We saw that people had been asked for their views about the agency and people had made positive comments regarding the care workers and the care provided. However, we saw one person had suggested the service could be improved by strengthening communication between carer workers when shifts changed. The registered manager was unable to demonstrate how they had actioned this recommendation to drive improvements. This was a breach of regulation 17 (1) (2)(a) (e)(f) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The registered manager told us they were aware of the agency’s shortfalls and had capped the number of people receiving support to enable them to concentrate on the improvements needed and recruitment. The management demonstrated a commitment to address any issues identified in a planned and structured way.

People spoken with told us that they were happy with the staff and services provided. Comments included; "they are grand, much better than the others who used to come here." People said their care had been planned by the manager and they had been involved in the decision making. They said that they had a copy of their care plan which was kept in a folder at their home. People said that they knew what they had agreed when the plan was written. They told us that the care workers delivered appropriate care.

From the staff records we looked at we were able to see that the staff who currently worked for the agency had been appointed correctly. That is, all of the appropriate checks and references, including obtaining Criminal Record Bureau disclosures [CRB’s] had been carried out. This showed that the provider had taken appropriate steps to ensure that there were safe recruitment procedures in place and that people who were not suitable to work with vulnerable adults were not employed within the service.

People said they felt safe and well supported by the agency.

Staff said they received adequate training to enable them to provide care appropriate to need.

The agency is in the process of recruiting more staff to enable the service to expand. They are also updating the care plans to ensure they are person centred and identify all aspects of how the care and support will be carried out.

The agency is in ifs infancy and currently only provide personal care and support for two people. We were unable to speak with these people as they were either unavailable or lacked mental capacity. However relatives told us that the service was reliable and consistent. Other comments included:

“staff are very reliable”,” staff carry out good quality care”;” staff understand peoples needs.”