What life is like for people using this service:

• Improvements were needed in how the provider assessed risks to people as there were inconsistencies across the records we reviewed. Although people told us that they did not have any concerns with how they were supported with their medicines, we saw that improvement was needed to ensure practice was in line with the National Institute for Health and Care Excellence guidance.

• People told us that they felt safe using the service and staff were confident that any concerns would be dealt with appropriately. The provider had a new electronic call monitoring system where staff logged in and out of their calls, which enabled care staff visits and punctuality to be monitored. Staff followed infection control guidance and had access to personal protective equipment.

• Care staff had the skills, knowledge and support required to meet people’s needs.

• People received support from care staff that were of a caring nature. The majority of people who used the service told us that staff were kind and caring and treated them with dignity and respect. People had regular care staff who knew how they liked to be supported.

• People consent was sought before staff provided care and staff understood the principles of the Mental Capacity Act. The provider had a system in place for responding to complaints. People knew how to complain however were not always confident their concerns would be acted upon.

• People and their relatives were generally satisfied with the service they received however we found that the service was not consistently well led. The systems in place to assure the safety, quality and consistency of the service were not consistently effective.

• This is the third consecutive inspection whereby the provider had failed to achieve an overall ‘Good’ rating.

We found a breach of regulation in relation to the systems in place to monitor and improve the quality of the service. You can see what action we told the provider to take at the end of the full version of this report.

More information is in Detailed Findings below.

Rating at last inspection: Requires Improvement (report published 3 October 2017 ).

About the service: GTG Care Nursing is a domiciliary care agency. It provides personal care to people living in their own homes in the community. At the time of the inspection they were supporting nine people, however not everyone was receiving the regulated activity of personal care. 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.

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up: We will ask the provider following this report being published to tell us how they will make changes to ensure they improve the rating of the service to at least Good. We will revisit the service in the future to check if improvements have been made.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

We carried out an announced comprehensive inspection of this service on 26 January and 07 February 2017. At that time we identified continued breaches of three legal requirements. This was because people were not protected by a safe recruitment system and the provider did not consider people’s capacity to make decisions about their care in line with the Mental Capacity Act (2005). The third breach related to good governance whereby the provider had not ensured adequate systems were in place to monitor the safety and quality of care that people received.

After the last inspection we met with the provider to discuss our concerns about the service. They also wrote to us to say what changes they would make to ensure they met the legal requirements and to consistently provide a well-led service.

This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for GTG Care Nursing on our website at www.cqc.org.uk

We carried out this announced focussed inspection on 04 August 2017. We undertook the inspection to check if the provider had followed their plans and to confirm that they were now meeting legal requirements. At this inspection we found that improvements had been made which meant they were now meeting the three areas of the law, further improvements were still required in some areas. We did not review the ratings at this inspection. We will do this when we next inspect all of the five key questions at this service.

GTG Care Nursing is registered with the Care Quality Commission to provide personal care for people in their own homes. There was a registered manager in post at the time of our inspection. 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 were protected from any risks associated with provider operating an unsafe recruitment system. We found the provider had taken steps to improve the system by ensuring staff had the correct documentation and legal checks were carried out to ensure staff were suitable to work with people who used the service.

People could be assured that their rights would be protected as staff had the knowledge and skills to implement the principles on the Mental Capacity Act.

People were protected by a governance system which ensured the quality of the care they received was monitored and steps taken to ensure where improvements were highlighted action would be taken.

This inspection took place on 26 January 2017 and 7 February 2017. At our last inspection completed in March 2016 we found the provider was not meeting the regulations in seven areas of the law. At this inspection we found some improvements had been made but the provider continued to be in breach of the law in some areas. You can read about this in the full report.

GTG care Nursing is a domiciliary care agency registered to provide personal care. At the time of our inspection the service was providing personal care support to 17 people living in their own homes. There was a registered manager in post at the time of our inspection. 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 were not protected by a safe recruitment system. Staff had not received adequate pre-employment checks which meant they may not be suitable to work with vulnerable people. Whilst staff knew how to recognise and report suspected abuse the registered manager did not have adequate knowledge to report suspected abuse. Staff knew how to manage people’s risks. Improvements were needed in identifying and recording people’s risks. People were supported by sufficient staff to meet their needs. People told us they received their medicines on time.

People’s rights may not be upheld as staff did not have sufficient knowledge of the Mental Capacity Act (MCA) and people told us their consent to care was not always obtained by staff. The registered manager had not implemented the principles of the MCA into their practice. People were supported by staff who had received training to meet their needs. People told us they received adequate support to meet their nutritional needs. Family members supported people to access healthcare professionals when they needed it.

People were supported by staff who were kind and considerate. People were supported to make day to day decisions about their care. People’s privacy and dignity was maintained by staff. Staff supported people to maintain their independence.

People were happy with the care they received and told us they were supported by staff who understood their needs and preferences and felt included in their care. Improvements were needed to ensure people’s care records reflected their choices and preferences and gave sufficient guidance for staff to follow. People told us they were happy to complain if needed. We saw when people and their relative’s complained we saw they did not always receive a response from the registered manager.

People were not protected by systems and quality assurance that identified where improvements were needed within the service. The quality assurance system in place was ineffective because it had failed to identify the areas highlighted in our inspection where improvements were needed. The registered manager had sought people’s opinion of the service they received. Staff felt supported by the registered manager.

We found the provider was not meeting all the regulations required by law. You can see what action we told the provider to take at the back of the full version of the report.

The inspection took place on 21 March 2016 and was announced. At the last inspection completed in January 2014 we found the provider was not meeting the regulations regarding assessing and monitoring the quality of the service and record keeping. At the most recent inspection completed in March 2016 we found the provider had not made the required improvements.

GTG Care Nursing is a domiciliary care agency registered to provide personal care and nursing care. We did not inspect the regulated activity of nursing care as there was no service being provided at the time of the inspection. At the time of the inspection the service was providing personal care support to 22 people living in their own homes. These people were mainly older people, some of whom were living with dementia. We confirmed with the registered manager that the regulated activity of nursing care was not currently being used by the provider, therefore, this regulated activity was not inspected. 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 were not always protected by a staff and management team who knew how to recognise and report signs of potential abuse. People were not protected by robust risk management processes. There were not robust systems in place to ensure people received the support they required to safely manage their medicines.

People were not protected by safe recruitment processes. Insufficient pre-employment checks were sometimes completed before staff members began work. The quality of service people received was often reduced due to insufficient staff levels.

People were not always supported by staff who had the appropriate skills to support them safely and effectively. People who had capacity to make decisions were supported to consent to their care. Where people lacked capacity decisions were not always made in line with the Mental Capacity Act 2005. Most people were supported to maintain their day to day health and received the support they wanted with their food and drink.

People felt most care staff were kind and caring although this was not consistent across the whole staff team; including management and office staff. People were supported to make day to day choices about their care and maintain their independence. People’s privacy and dignity was protected and upheld.

People’s care did not always meet their needs and preferences. People were not always involved in the planning of their care and regular reviews. People’s complaints were not always recorded and responded to appropriately.

People were not protected by strong systems and quality assurance that identified potential risks and areas for improvement within the service. The registered manager had not developed a culture that accepted and recognised the shortfalls in the service and made clear plans to improve the service provided to people.

We found the provider was not meeting all of the regulations required by law. You can see what action we told the provider to take at the back of the full version of the report.

This inspection was completed as part of our planned programme. We told manager we were visiting two days in advance. This was to make sure that people we needed to speak with were available. As part of this inspection we spoke with people that received a service, relatives, care workers and a manager from the agency.

Everyone we spoke with told us they were happy with the care they received. One person said: "I'm satisfied. The girls are nice". A relative said: "They are very good. No problems at all with the carers".

An assessment was completed before people received a service. Plans of care were limited and needed to be more focused on each person's needs and their individual preferences. People told us that the care met their needs. They said that they got on with the care workers and they knew how they liked their care.

The agency was making sure checks were made before new staff were employed. Care workers received induction and ongoing training that supported them to meet the needs of people they provided care for.

The agency had few formal systems to check the quality of the service people received. People's views were sought through an annual survey. A complaints procedure was in place and people were confident that the agency would act on any concerns.

Records held in the office were kept securely but were not accurate and were not kept up to date.

During this inspection we conducted telephone interviews with one person who uses the service, one person’s relative and three care staff.

People told us they had the information they needed to help them make choices about whether or not they wanted to use the service. They told us that they were involved in agreeing their care and that the staff treated them with dignity and respect and observed their privacy and independence. One person said: “I feel they treat me with dignity and respect. They don’t rush me, I try to do a lot and they do the things I can’t do. They talk to me and we have a laugh and a joke.”

We found that people received the care they needed and that procedures were in place to ensure the care is delivered safely and as agreed with the person using the service and their relatives. We saw that the provider took account of people’s diverse needs whilst delivering the care. People told us they were happy with the care they received and had no concerns whatsoever about the service. One person told us: “We have been receiving a service from this agency for the last three years. Mom was recently discharged from hospital. Her needs have changed and she now requires two carers four times a day. I feel they will be able to meet her needs. I am satisfied with the service so far.”

People told us they felt safe using the service and with the staff that visit them. We found that people who use the service were protected from the risk of abuse, because the provider had systems in place to help to identify and prevent abuse from happening.

We found that people receive a service from staff that were generally trained and supported to meet their needs. Staff we spoke with were confident in their role and people we spoke with told us they had confidence in the staff.

People told us that they were able to raise their concerns with the provider and felt they would be acted upon. People told us their care was reviewed and they were asked their views on the quality of the service they received. We found that the provider generally monitors the service delivered to ensure that it meets the needs of the people supported.

We spoke with two people who use the service and their relatives. They told us that they were involved in agreeing the care and support they received. They said they were treated with respect and dignity by the staff. They said the service met their needs. One person said. “They have been reliable up to now.” Another person said. “They stick to the plan and we are pleased with the service.”

During our visit to the service we saw that people’s needs were not routinely assessed. We saw that the registered provider was not always assessing the risk of providing the care and support to people who use the service. The records we saw were not agreed by people who use the service or their representatives, so we could not tell if everyone was involved in planning their care.

We found thatthe failure to assess the risk of providing the care for people who use the service, means they are not fully safeguarded from harm.

We saw that the registered provider did not have a robust system for showing that staff received the training and supervision they needed to do their job well.

We saw that effective systems are not in place to monitor the quality of the service provided.