This inspection took place on the 28 and 29 June and 5 July 2018 and was announced.

We previously carried out an announced inspection at the service on 22 and 23 March 2017, where we identified shortfalls to the care provision and the service was rated as Requires Improvement. We identified two breaches of the relevant regulations relating to good governance and the failure to submit statutory notifications. 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 Safe, Effective and Well-led to at least good. At this inspection we found that improvements had been made in some areas, however further work was still required. We found that the registered provider was no longer in breach of regulations relating to notifications. However, they remained in breach of regulations relating to good governance.

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 people living with dementia, learning disabilities or autistic spectrum disorder as well as physical disability and sensory impairment.

Not everyone using Kare plus Cheshire receives a regulated activity; CQC only inspects the service being received by people provided with ‘personal care’; such as help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided. At the time of the inspection there were 59 people receiving personal care.

There was a registered manager at the service. 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.

Since the last inspection, action had been taken to try to improve the recording of information relating to the management of medicines. However, shortfalls remained and we found that information relating to medications was insufficient. There were gaps in the guidance for staff around the administration of PRN (as and when required) medicines and topical creams. The registered manager had started to take action to address these concerns during the inspection.

Sufficient numbers of staff were deployed to provide people's care and support. However, we found that occasionally people received late visits or staff did not stay the full allocated time. We saw that travelling time was not included in staff schedules, which could impact on the timeliness of visits. The registered manager assured us that she would review the organisation of schedules.

Risk assessments had been carried out; however, the assessments had not always included all relevant information or been updated in line with people's changing needs. Appropriate recruitment procedures were followed to ensure prospective staff were suitable to work in the service.

The provider had taken some action to address issues raised at the last inspection regarding compliance with The Mental Capacity Act 2005 (MCA). However, we found there continued to be gaps in staff understanding of the MCA and mental capacity assessments were not always available when people were unable to consent to their care. We made a recommendation in relation to compliance with the MCA.

Improvements had been made to the training arrangements and a new provider had been sourced. Staff were positive about the support they received. We saw that staff received supervision and field observations were also undertaken.

An initial assessment of people's support needs was undertaken for all new referrals. The management team under took visits to people to discuss their care needs. People's nutritional needs were met as required.

People were positive about the approach and attitude of staf

The inspection took place on 22 and 23 March 2017 and we gave the provider 48 hours’ notice. This was to ensure that someone would be available in the office as it is a domiciliary care service. The service has not been previously inspected. At the time of our inspection there were approximately 85 people using the service with a range of support needs such as dementia, physical disability and older people.

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.

This was the service’s first inspection since it was registered. At this inspection we identified breaches of 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.

The service was not consistently safe. Risk assessments sometimes lacked detail or were blank. Some people had support needs which had not been taken into account in the risk assessments, such as equipment used for mobilising and help to keep skin healthy.

Medicines were not always managed safely. People who required support with their medicines did not always have records of medicines being administered and there was information missing from some medicine records so there was a risk of staff not giving medicines as prescribed. There were also no protocols in place for medicine that were ‘as and when required’ (PRN) so this put people at risk of not having their medicines when they needed them.

Mental capacity assessments were not being carried out so it was not possible to determine how the service was protecting people in line with the Mental Capacity Act 2005. By not assessing capacity the service was verifying whether representatives with Lasting Power of Attorney had the right to make decisions on behalf of people. People and staff confirmed that people were supported to make their own decisions and consent was gained before staff gave support. Therefore not all of the principles of the Mental Capacity Act 2005 (MCA 2005) were being consistently followed.

The service was not consistently well-led as some audits had not always identified that there were omissions in documentation, such as medication administration records, missing risk assessments and missing information about the support some people needed. Improvements had been planned in some cases; however these had not yet been completed.

The service had not always notified the CQC about significant events that they are required to send us by law.

Staff did not always feel the online training was sufficient and felt that more face to face training would be more beneficial. Despite their feelings on training, staff felt supported in their role as they had supervisions and felt they could ask questions when necessary.

People told us they felt safe. People were also protected by the risks of potential abuse as staff knew what abuse was, how to recognise it and how to report suspicions of abuse. People and staff told us they felt there were enough staff and most people felt they had regular staff. We found staff were recruited safely.

People had access to other health professionals. Both people and other health professionals told us the service worked with them.

Most people we spoke to could prepare their own food or were supported by relatives to make their meals throughout the day. Of those who were supported by staff, they felt staff did this well and were encouraging.

People and relatives all told us they found the staff to be caring and that they treated them with dignity and respect. Staff offered explanations when needed and people were encouraged to retain their indep