Passion Healthcare Ltd is a domiciliary care agency providing personal care for people in their own homes. The service provides personal care for older people and younger adults. This was a comprehensive inspection.

The inspection took place on 11 and 12 June 2018. The inspection was announced because we wanted to make sure that the registered manager was available to conduct the inspection.

At our last comprehensive inspection in May 2016 we rated the service as 'Good'. On this inspection improvement was needed to ensure that people were comprehensively safe and that quality assurance systems had not been effective in driving improvements in the service. Because of these issues, the overall rating for this inspection has reduced to 'Requires Improvement.'

A registered manager was in post. This is a condition of the registration of 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 and associated Regulations about how the service is run.

Risk assessments were not comprehensively in place to protect people from risks to their health and welfare.

Policies set out that when a safeguarding incident occurred management needed to take appropriate action by referring to the relevant safeguarding agency and to CQC. This had not been carried out for a potential suspicion of abuse.

Management had carried out audits in order to check that the service was meeting people's needs and to ensure people were provided with a quality service, though some issues had not been checked including issues which were identified on this inspection.

Staff recruitment checks were carried out to protect people from receiving personal care from unsuitable staff.

People and relatives told us they thought the service ensured safe personal care was provided by staff. Staff had been trained in safeguarding (protecting people from abuse) and understood their responsibilities in this area.

People told us that staff supported them with their medicines and records had shown this had happened.

Staff had received training on core important topics to ensure they had skills and knowledge to meet people's needs, though training on other relevant issues had not yet been provided.

Staff understood their responsibilities under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) to allow, as much as possible, people to have effective choices about how they lived their lives. Staff were aware to ask people’s consent when they provided personal care. Mental capacity assessments were in place.

Most people and relatives told us that staff were friendly, kind, positive and caring. Not everybody told us they had been involved in making decisions about how and what personal care was needed their needs, though they did not feel this had any impact on the quality of care they received.

Care plans included important information on people’s needs, which helped to ensure that their needs were met, though there was not comprehensive information in place on people’s lifestyles and preferences.

People and their relatives were confident that any concerns they had would be properly followed up. Most were satisfied with how the service was run.

Staff members said they had been fully supported in their work by the management of the service.

We found two 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 this report.

Passion Healthcare provides personal care for people living in their own homes. On the day the inspection the manager informed us that there were 36 people receiving personal care from the service.

We previously carried out an unannounced inspection of this service in November 2013. Breaches of regulations was found relating to a failure to fully promote people's welfare, checking that staff were fit to provide personal care to people and a lack of quality checking of services supplied to people.

After this inspection we asked the provider to produce an action plan stating what they would do to meet legal requirements in relation to the breaches. The provider sent this to us. This outlined action that would be put in place to ensure that these breaches in regulations were rectified. We found action had been taken to meet these breaches.

A registered manager was not in place. 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 and associated Regulations about how the service is run. The current manager stated that she would submit an application to be the registered manager of the service within a month of this inspection visit.

People and their relatives we spoke with said they thought the agency ensured that people received safe personal care. Staff had been trained in safeguarding (protecting people from abuse) and staff understood their responsibilities in this area.

Risk assessments were detailed to assist staff are to support people safely.

We saw that medicines were supplied safely and on time, to protect people’s health needs.

Staff had been safety recruited to ensure they were appropriate to supply personal care to people.

Staff had training to ensure they had the skills and knowledge to be able to meet people's needs, though more training was needed to ensure all people’s needs could be met.

Staff understood their responsibilities under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) to allow, as much as possible, people to have effective choice about how they lived their lives.

Staff had awareness of people's health care needs so they were in a position to refer to health care professionals if needed.

People and their relatives we spoke with told us that staff were friendly, kind, positive and caring.

People, or their relatives, were involved in making decisions about how personal care was to be provided.

Care plans were individual to the people using the service is to ensure that people's individual needs were met to ensure a fully personalised service was provided to them.

People or their relatives told us they would tell staff or management if they had any concerns and were mostly confident any issues would be properly followed up.

People and their relatives were satisfied with how the service was run by the management. There were comments for improvement from staff to ensure they were fully supported in their work.

Management carried out audits and checks to ensure the agency was running properly and ensure people were provided with a quality service.

We spoke with three people who use services and three relatives during our inspection. One person told us, “I’ve got a file and it tells me the agency telephone numbers and all you need to know.” A relative told us: "The staff have helped my family member she eats better and her health is improving. I phone the agency and leave messages and they are always passed onto the support workers. It is a very good agency." People told us that they were very satisfied with the care and support they received. One person said: “I am happier with this agency, they are very caring.” A relative told us: "The staff are really good and make my family member happy, so I am happy.” People told us that they felt safe with the support workers who visited them. One person said: “I have the same staff and know them well, they are reliable.” Another person told us, “I do feel safe, I have no concerns at all.” People told us that they knew what to do if they had any concerns or worries about the care and support they received. We found the service was non compliant around care planning, staff recruitment procedures, and monitoring the quality of service.