This service is a domiciliary care agency. It provides personal and nursing care to older adults, younger disabled adults and children, living in their own homes in the community. At the time of our inspection 19 people including 14 children and five adults received a service. Some children and adults had complex health care needs. Some staff worked with both children and adults.

This announced inspection took place on the 8 and 9 October 2018. During our previous inspection in September 2017 we found several breaches of the regulations, this was because records were not always up to date and accurate. Risks had not always been identified or minimised. There were not always sufficient numbers of trained staff available to meet people’s needs. The staff did not always practice in line with the requirements of the Mental Capacity Act 2005.

We also found the provider could not be assured staff had the competence or skills to carry out specific tasks. This was because the staff were not always tested or observed. People complained to us about the poor communication they experienced with the office staff. This had caused some distress. 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; responsive and well-led to at least good. During this inspection we found improvements had been made in all areas.

At the time of this inspection there was no registered manager in place, however a candidate had applied to the commission to be registered and was completing the registered manager’s application process. 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’s relatives told us they believed the service was safe. Risk assessments had been completed for care and the environment. Where risks were identified these had been minimised. The risks to people and staff were regularly reviewed. Trends were identified and action taken to prevent a reoccurrence where possible. Care plans gave guidance to staff on how to reduce risk and included people’s needs and preferences. People’s needs were assessed prior to receiving care.

Staff received an induction which included training. They received support through supervision and appraisals. Specialist training was provided to ensure they could meet people’s individual needs. Competency assessments took place to ensure staff where meeting the required level of skills and knowledge.

Staff received training in how to identify signs of abuse. Records showed appropriate action had been taken when concerns were raised. This helped protect people from harm. Safe recruitment systems were in place to minimise any risk that unsuitable staff were employed to work with people.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice.

People’s relatives told us the staff were supportive and described them as “Brilliant”, “Gentle” and “Very good”. People’s healthcare needs were met through the involvement of external professionals and the co-operation of Phoenix staff.

People or their relatives were involved in the planning and review of their care. Regular contact was made with people to ensure they were happy with the delivery of care and to discuss any changes that may have been required.

Where people had communication difficulties, staff were trained to ensure their ability to communicate was enhanced. People were assisted to remain as independent as possible and staff understood how to protect people’s privacy and dignity. People received support to participat

This announced inspection took place on 5 and 6 September 2017. Phoenix Medical Advice And Repatriation Limited provides care including nursing care to children and adults in their own home. At the time of the inspection the service was providing support to adults and children in their own homes, sixteen of whom were receiving personal care.

A registered manager had been in post for six weeks prior to the inspection. During this time they had identified a number of areas that required improvements. They had developed a service development plan, which had documented these areas. We saw that some changes had been initiated.

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 had been left without staff to cover their visits due to a shortage of staff. Staff rotas had not been completed accurately and staff were sometime expected to work long hours to cover for staff absence or gaps in the rota. The provider was planning to introduce a rapid response team to address these issues.

Medicine records were not filled in accurately. Information related to the prescribed medicine was not comprehensive, and unexplained gaps were found on a number of Medicine Administration Record (MAR) charts. Checks carried out by the lead nurse did not identify the concerns we found.

Recruitment practices did not evidence that gaps in employment history had been followed up with candidates. We have made a recommendation to the provider regarding safe recruitment systems.

Mental capacity assessments had not always been completed, and the best interest process had not always been followed. This meant people were not supported to have maximum choice and control of their lives. For one person it did not appear that staff supported them in the least restrictive way possible as restrictions were placed on the number of visitors without a stated good reason.

Staff received training and support to carry out their role. However, we found competency checks and observations were not always carried out, which meant the provider could not assure themselves, staff were carrying out care in a safe and appropriate way.

The registered manager had put plans in place to ensure staff supervision and appraisals were to be carried out regularly.

People had support with their food and fluid intake. Where people required medical support this was arranged to help them maintain good health.

People’s relatives told us staff were positive and caring. We were given examples of where staff had gone over and above their required duties to assist people. Staff showed concern for people in a caring and meaningful manner. Staff showed respect for people and understood the importance of enabling people to be as independent as possible.

Records did not consistently demonstrate the service had identified and assessed monitored and mitigated risks to people's health, safety and welfare. Care plans and risk assessments were not detailed and did not cover all areas of risk to people or staff.

People and their relatives had struggled to maintain effective communication with office staff. Relatives told us concerns they shared with the office were not responded to. The provider was not fulfilling their role of listening to people and addressing problems or concerns in a timely manner. A lack of leadership and oversight of the service had led to staff feeling stressed and upset. With the introduction of the new registered manager some relatives told us they had seen a slight improvement in communication.

The provider had failed to put in place effective audit tools, to monitor and improve the service delivery. The registered manager had developed a service improvement plan and was wor