The inspection took place on 1, 2 and 7 February 2017. This was an announced inspection and the provider was given 48 hours' notice of our visit. This was to ensure that someone would be available at the office to provide us with the necessary information to carry out an inspection. When we last visited the service in October 2015 it was identified that the service needed to improve with medication management. We saw that this had been addressed within a month of the last inspection.

The head office is in the Padgate area of Warrington and is accessed via the ground floor.

Nightingales provides care and support to people in their own homes. They work with people who are elderly, disabled or have additional needs to help them remain independent at home. At the time of the inspection there were 129 people using the service. .

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. The registered manager is also the owner and director of the company.

People were treated with dignity and respect. Staff understood people's preferences, likes and dislikes regarding their care and support needs. However care plans were inconsistent. Whilst they all held basic details of the persons needs some were detailed and included people’s preferences and choices, whilst others would benefit from more person centred information.

Staff recruitment processes were robust, however information on staff files was sometimes difficult to find. They would benefit from a more structured format to include a referencing index.

People told us they were safe. Medicines were managed safely. Risk assessments identified the risks to people and how these could be minimised. Sufficient numbers of staff were available to meet people's needs.

People were involved in decisions about their care and how their needs would be met. Managers and staff had received training on the Deprivation of Liberty Safeguards and the Mental Capacity Act 2005.

Staff had access to on-going training. They were knowledgeable about their roles and responsibilities.

Staff knew how to respond to people's needs in a way that promoted their individual preferences and choices regarding their care. Where necessary people’s nutritional needs were well met and they had access to a range of professionals in the community for advice, treatment and support.

Care was planned and delivered in ways that enhanced people's safety and welfare. However home visits were not always provided in a timely manner.

People were supported to maintain good health and had access to healthcare services. Staff supported people to attend healthcare appointments and liaised with their GP and other healthcare professionals as required to meet people's needs.

People had access to the complaints procedure and told us that they knew how to make a complaint should they need to. We found that the management team had regular contact with people and dealt with any issues and concerns as they arose.

The service regularly requested feedback from people who use the service. People, relatives and staff said the management were approachable and supportive.

Systems were in place to monitor the quality of the service. People felt confident to express any concerns and these were addressed by the registered manager.

The inspection was carried out by a pharmacist inspector. We set out to answer three key questions; Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with the manager and other staff and looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Most people received their medicines when they needed them and in a safe way. Arrangements for some people however, were unclear and this placed them at unnecessary risk of harm. Medicines were administered appropriately by trained care workers and, where necessary were kept safely in people’s homes.

Is the service effective?

We found that care plans for managing medicines were in place and care workers had clear information to follow to ensure that people were supported to take their medicines safely. Medication records were incomplete and it was not always possible to see exactly what medicines had been administered.

Is the service well led?

We saw that audits, or checks of medicines, were carried out regularly to assess the way medicines were managed and to ensure that people continued to receive the support they needed.

We spoke with three people who used the service and they told us that they were well looked after by kind and helpful staff.

People said staff gave them the attention they required.

Staff spoken with demonstrated their understanding of peoples needs and of how to provide needs led care and support to the people who used the service.

Care records showed that people's individual needs and preferences had been taken into account and that people had been given a choice in how they wished to be cared for.

Care records showed that a person's independence was actively supported. Staff were knowledgeable about a person's care and gave examples of how they treated people with respect and dignity and promoted people's independence.

Mediation was generally well managed. However medication records were not always clear. The records did not evidence that people were receiving the correct levels of medication.

We spoke with six people who used the service and three of their relatives. People told us they believed their care needs were being met and were confident in the care they received from staff. People also reported that they had been visited by the manager of the agency to discuss their needs prior to using the service and confirmed staffing was reliable and consistent. People told us that staff provided detailed information before the service began. This included the agency statement of purpose and the rights of each person to lead as independent and individual life as possible. People said they were treated with dignity and respect and their views were taken into consideration by management and staff.

Comments received included "Staff have never let me down”;” Staff are generally on time and when they are late they let us know" ”The staff are kind and considerate and treat people with respect."

People told us that “Staff are friendly and make me feel at ease”, “The staff treat me well and I am totally comfortable with them”, "Staff certainly know what they are doing."

People told us that they were encouraged to speak their mind about the staff and services provided. One person said that they had been given a questionnaire to complete about the service. Another person told us that staff carried out reviews of care and people were asked their opinions of the care provided.

We spoke with people using the service in order to gather their views about the care provided by the agency.

People told us that staff provided detailed information before the service began. This included the agency statement of purpose and the rights of each person to lead as independent and individual life as possible. People said they were treated with dignity and respect and their views were taken into consideration by management and staff.

People told us they believed their care needs were being met and were confident in the care they received from staff. People also reported that they had been visited by the manager of the agency to discuss their needs prior to using the service and confirmed staffing was reliable and consistent.

Comments received included "Staff are reliable and give good service. Staff know what care and support I need and look after me well”.

This inspection took place on 29 and 30 September and 1and 15 October 2015. We visited people who used the service in their own homes on the first and second day of the inspection and on the third and fourth day spoke with people who used the service and staff on the telephone. We visited the offices of Nightingales UK Limited (Nightingales) on the first three days of the inspection.

The service was last inspected in July 2014 when it was found that medication records were incomplete and it was not always possible to see exactly what medicines had been administered. An action plan was provided by the service to advise what steps they had taken to rectify the situation.

At the time of this inspection the provider was supporting101 people with personal care in their own homes. The majority of people who used the service were older people. Most of the service was commissioned by Warrington Borough Council.

There has been a registered manager at Nightingales continuously throughout its registration with the Care Quality Commission (CQC). 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 found a breach of the Regulation relating to medicines. Medicines were not always administered safely, we could be satisfied that people had received the care planned for them however not always at the agreed time. Medication records were not always kept accurately. You can see what action we told the provider to take at the back of the full version of the report.

We found that the service provided by Nightingales required improvement to the staffing rotas. People who used the service did not feel that they were always informed if staff were not going to attend at the agreed time. Quality assurance systems had identified the improvement needed and the registered manager had commenced the improvements to the call alert system which they identified were required.

People who used the service felt safe and staff were checked as suitable for their role, inducted into it and then trained so they could do their jobs. People who used the service liked the staff and were complimentary about them. Care plan documentation varied in its format. However it was generally easy to understand and was designed around the needs of people who used the service. Management had access to good information about the service and had implemented some communication systems such as providing staff with mobile telephones and arranging staff meetings and supervision.