PJ’s community service limited is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community. Not everyone using the service receives a regulated activity. 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. At the time of our inspection seven people were receiving support with their personal care.

We undertook an announced inspection on 15 May 2018. At our last inspection on 14 December 2016 we rated the service ‘good’. At this inspection we identified breaches of legal requirements and the rating for the service had deteriorated to ‘requires improvement’.

A registered manager was 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.

The service did not have a robust quality assurance system in place which addressed all areas of care delivery and staff support. There were not sufficient systems in place to ensure complete, accurate and contemporaneous records were maintained. Whilst staff were aware of the risks to people’s health, safety and welfare, sufficient information was not included in people’s care records about these risks or how they were to be managed. People received care and support that met their needs. Staff were aware of people’s preferences and had built up familiar routines. However, care records did not provide detailed information about people’s needs and complete, up to date records were not maintained.

Staff had not completed sufficient refresher training courses to ensure they had the knowledge and skills to support people in line with current good practice. Staff did not receive regular supervision.

The registered manager had not adhered to their CQC registration requirements and had not submitted statutory notifications as required. The provider had also not displayed their rating on their website so this information was not made accessible to people.

There were sufficient staff to meet people’s needs and to ensure consistency in the staff providing support to people. Staff adhered to the provider’s incident reporting process and safeguarding adults’ procedures. Staff followed procedures to ensure people received their medicines as prescribed and to prevent the development and spread of infections.

Staff supported people in line with the Mental Capacity Act 2005 and respected people’s decisions. Staff provided people with any support they required with meals and supported them to access healthcare services if feeling unwell.

Staff built kind, caring and compassionate relationships with people. The consistency in care workers meant staff knew people’s routines. Staff respected people’s privacy and dignity. Staff communicated with people whilst providing support and ensured people were engaged and involved in their care. People were aware of who was important in people’s lives and respected people’s preferences and beliefs.

There was an open culture within the staff team. Staff felt well supported and able to express their views and opinions. The provider had used other assessment processes, including local authority quality visits, to make improvements to the service. A complaints process was in place and people felt able to raise concerns with the management team. Staff learnt from the complaints made to improve service delivery.

The provider was in breach of legal requirements regarding good governance, submission of statutory notifications and displaying ratings. You can see what action we have asked the provider to take at the back of the main report.

This inspection took place on 14 December 2016. The provider was given 48 hours’ notice of the inspection because the service provides domiciliary care and we needed to be sure the manager was available. The service was meeting the Regulations at our last inspection.

PJ's Community Service Limited provides care and support to approximately 14 adults with varying needs in their homes.

The service has 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.

People told us they felt safe with this service. Staff understood their responsibilities in relation to reporting abuse and had attended relevant safeguarding training. Risk assessments reflected people’s needs and supported staff to provide safe and appropriate care and support. There were sufficient numbers of suitable staff to meet people’s needs. Staff went through an appropriate recruitment process before being employed. People’s medicines were administered and managed safely where required.

Staff received regular training and management support. Training included an induction process for new members of staff and refresher training for existing staff. Training, management supervisions and appraisals took place periodically. The service was working within the principles of the Mental Capacity Act. People consented to their care and support.

People and relatives told us staff were caring and treated them with dignity and respect. The service supported people to be involved in planning their care and support. Staff respected people’s dignity and privacy and encouraged people to be as independent as they wanted to be. Staff encouraged and enabled people to make choices and respected people’s preferences.

The service was responsive to people’s needs. Other than urgent placements, people’s needs were assessed before the service started providing care and support. Care and support plans were person centred and identified needs and preferences. The service encouraged feedback from people and their representatives about their experiences of the service. The service had an appropriate system for dealing with complaints.

People, relatives and staff spoke positively about the registered manager. There were systems to obtain feedback from staff including staff meetings. Any accidents or incidents were reviewed by the registered manager to identify and implement any learning or improvements. There were systems and processes to monitor and assess the quality of service provided. Records were fit for purpose.

The inspection was carried out by one inspector.

We considered our inspection findings to answer questions we always ask. Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, their relatives, and the staff who supported them and from records we looked at. These included policies and procedures, minutes of staff meetings, care records and staff files, including their training certificates. We also looked at records relating to quality monitoring and quality assurance systems and complaints. We spoke with two people who used the service, three relatives and seven staff, including the registered manager.

Is the service safe?

People who used the service had not been protected against risks associated with the unsafe use and management of medicines. This was because staff had not accurately recorded medicines administered to people.

Risk assessments had been undertaken to identify any potential risk and action plans produced to manage risks. Staff were familiar with these plans and strategies for minimising risks. We found people were not put at unnecessary risk in relation to their care and support whilst retaining choice and control of decisions affecting them.

Systems were in place to ensure staff learned from adverse events such as accidents, incidents, complaints and concerns. This helped to reduce risks to people and promoted continuous service improvements.

Is the service effective?

People’s health and care needs had been assessed with them and their care and support plans were up to date, reflecting their current needs.

The service was not effective in relation to omissions in record keeping practices for medicines.

Staff had received training to ensure they had the necessary skills to meet people's needs.

People and their relatives we talked to felt the service was effective.

Senior staff comprising of the registered manager, operations manager and care coordinator were always accessible to staff for advice and support.

Is the service caring?

People told us staff respected their rights and dignity in the way they performed their duties and interacted with them. They said they were involved in planning their care packages and had agreed their care plans. Though staff provided the care and support written in their care plans people told us staff were flexible if asked to carry out other tasks, if they had time.

Records showed people’s preferences, interests, aspirations and diverse needs had been recorded. People said the care and support received was in accordance with their wishes. Feedback from people and their relatives was positive in regard to care staff’s conduct, attitude and practice. Comments included, “I have had the same carer for many years and am very happy with the way she supports me”. Another person said, “I feel the carers do their job well and they are all very good. My main carer is not working at present and I miss her. We have a very good relationship and she takes an interest in my life. She understands I have a poor memory and helps me by reminding me of things I need to do. Staff always do things the way I like them done and respect any changes I request to my care plan”.

The staff we talked with demonstrated good understanding of people's needs and gave examples of how they promoted their independence.

Is the service responsive?

People and relatives acting on their behalf knew how to make a complaint if they were unhappy with their service. We found appropriate procedures in place to respond to and record any complaints received. Records showed staff had been responsive to the complaints by providing alternative care staff. People and other relatives were happy with the way the provider had dealt with their concerns. They said senior staff had listened to them and were responsive to their requests, for example, for a change to the times of visits.

Is the service well-led?

Discussions with staff showed they were clear about their roles and responsibilities. They demonstrated good understanding of the agency’s ethos and commitment towards their work.

Staff supervision and support was provided through a combination of systems. These included one-to-one and group supervision sessions and visits by the care coordinator and operations manager to monitor care practice. The operations manager was directly involved in service delivery for individuals requiring two staff for specific interventions as part of their care packages. This presented further opportunity for senior staff to observe and assess staff practice. Collectively these systems helped ensure people received a safe, good quality service.

People and their relatives told us that from time to time the operations manager and care coordinator visited or telephone them to check they were satisfied with the service received and to establish if any changes were required to their care package. This showed the views of people or others acting on their behalf had been sought, enabling the registered manager to come to an informed view regarding standard of care and service provision.

The agency provided a service to 24 people, approximately half of whom have been referred by the London Borough of Croydon, with the remaining number being private clients. We spoke with people who used the service, care workers and a local authority commissioner about the service.

People who used the service told us that they were happy with the care and support that they were receiving. Comments included “the workers are very good” and “I’m happy with them”. People told us that they had consistent care worker coming to them most of the time. If the same care worker was not able to come, then generally they were told beforehand by the office staff.

People who use the service were also positive about the fact that care workers were matched where possible on ethnicity. This meant that they had a shared experiences, languages and understanding.

People who use the service told us that they were happy with the care and support that they were receiving.

They told us that they had consistency with the same carers coming to them most of the time. If the same carer was not able to come, then they either knew beforehand or were informed by the office staff; people really valued this.

People who use the service were also positive about the fact that carers were matched where possible on ethnicity. This meant that they had a shared experiences, languages and understanding.