The inspection was announced and took place on 10 and 11 December 2018. This was because this service provides care to people in their own homes and we needed to ensure senior staff were available to speak with us.

Total Care is a domiciliary care agency providing personal care to people living in their own homes. At the time of the inspection, the service was providing support for 88 people.

The service was run by a sole provider, Mrs Deborah Clarke. A sole provider is not required to employ a registered manager. Instead they can opt to manage the service themselves. 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.

Total Care is registered for the regulated activity of personal care. It is a domiciliary agency which provides care and support to people living in their own home. This included people receiving packages of care at the end of their life.

Total Care was previously inspected on 16 and 17 March 2016. The overall rating for the service was good.

At our last inspection we identified concerns in relation to the agency's recruitment procedures. Recruitment procedures did not fully protect people. Staff files seen did not always give information about staff conduct in their previous employment which could possibly place people at risk of receiving care from staff who were not suitable to work with vulnerable people.

At this inspection we found improvements had been made. All necessary checks were being carried out examining at least two employment references and employment history. Staff had been recruited safely

Care records had been reviewed and updated where necessary. Staff had travelling time built into their rotas. Staff had received one-to-one supervision, which provided them with opportunities to discuss their professional development and training needs. Spot checks had been carried out to check that staff were providing care safely and in the way people preferred.

People's records provided information about the medicine they were prescribed and who was responsible for its administration, such as family members or staff. Staff signed records, where they had the responsibility for administering medicines or applying prescribed creams.

Staff attended safeguarding training and understood how to recognise and report abuse. Staff understood risks involved in people's care and managed these well. The provider had developed a contingency plan, which prioritised the delivery of care to people most at risk in the event of an emergency. Staff helped people keep their homes clean and maintained appropriate standards of infection control.

Staff had access to the training they needed to carry out their roles. People's care was provided in accordance with the Mental Capacity Act 2005 (MCA. Staff had received training on the MCA and understood its principles.

People's nutritional needs were assessed during their initial assessment and any dietary needs recorded in their care plans. Staff understood people's healthcare needs and supported them to maintain good health.

Staff were kind and caring. People had developed positive relationships with staff members and enjoyed their company. Relatives said staff treated their family members with respect and maintained their dignity when providing care. Staff supported people to maintain their independence wherever possible. Care plans provided guidance for staff about people's needs and the way they preferred their care to be provided.

The agency was providing end-of-life care at the time of our inspection. The provider had an end of life care policy, which gave guidance to staff if they had to provide care to a person now. Care records also contained peoples end of life wishes.

Staff worked in partnership with healthcare professionals, such as community nurses, to provide people's care. People had opportunities to contribute their views about th

This inspection was announced and took place on 16 and 17 March 2016. We gave the provider short notice of the inspection as we needed to make sure we were able to access records and gain permission from people who used the agency to visit or telephone them.

Total Care is registered for the regulated activity of personal care. It is a domiciliary care agency which provides care and support to people living in their own homes. At the time of the inspection there were 88 people receiving a service from the agency. This included people receiving packages of care at the end of their life.

The last inspection of the service was carried out in September 2014. No concerns were identified with the care being provided to people at that inspection.

The service is run by Mrs Deborah Clark as a sole provider. As a sole provider she is not required to employ a registered manager. Instead she has opted to manage the service herself. 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.

Some improvements were needed to make sure the recruitment process fully protected people. Staff files seen did not always give information about new staff’s conduct in their previous employment which could possibly place people at risk of receiving care from staff who were not suitable to work with vulnerable people.

People felt the service was well run and efficient. Care staff were reliable and arrived at the correct time and stayed for the specified period. The provider told us they had high standards and expected high standards from the staff who worked for the agency. One person said “They have very high standards and are extremely caring. That comes from the top.”

People praised the staff who supported them and office staff who were always available to answer their queries and respond to changes. People had built good relationships with staff and felt safe and comfortable with the care staff who provided their personal care. Comments about staff included; “The carers that visit me are all fantastic” and “They always ask if there is anything else you want. They go that extra mile and that means so much”

Staff respected people privacy and provided care in a manner which respected their dignity. One person told us “They are so kind and respectful, they just deal with whatever I need. There is never a fuss.” Staff offered people choices about all aspects of their care. They had received training to assist them to support people who did not have the mental capacity to make a decision for themselves.

People received care and support in line with their needs and wishes because adequate numbers of staff were employed. There were contingency plans in place if staff were unable to carry out their visits. Staff were well trained and had the skills and experience required to support people effectively. They monitored people’s health and sought advice and support from healthcare professionals where appropriate. One person said “They know when you’re not yourself. They’ve helped me get the doctor in the past.”

People were fully involved in planning and reviewing their care. We were told the service was flexible to meet people’s changing needs and wishes. Care plans gave information about people’s likes and dislikes as well as their physical needs. This made sure staff knew how people liked to be supported and the things that were important to them. One person said “They follow my routine completely. They all know how I want things done.”

People knew how to make a complaint and everyone asked said they would be comfortable to raise any issues with a senior member of staff or the provider. When concerns had been raised these had been effectively dealt with.

We used a visit to the agency and spoke with two service commissioners to obtain information about the service. We made telephone calls to people who used the service and their main carers to gain their views about the service. We spoke with the provider and five care workers.

All of the people we spoke with gave positive feedback about the service and said that care workers respected their choices about the way care was delivered. A relative told us that “the service is excellent I would not have them in the house unless it was.” People told us they would use the service again and recommend it to other people.

People said they felt safe using this service and knew what to do if they had any concerns. We were told they had been contacted by the provider before and immediately after the service had started. People said they felt confident about contacting the provider if there were any issues.

We heard that people felt comfortable with the care workers, one person said "they are very flexible and understand how quickly things can change."

On our last visit we found the provider did not have an effective system to regularly assess and monitor the quality of service that people received. On this visit we found this had been addressed and feedback about the service obtained on a regular basis.

We used home visits to people who used the service and to their main carers (a relative or friend) to gain views about the service. We visited three people in their own home and spoke with them about their experiences of the support they received. We spoke with the provider and three care workers.

All of the people we spoke with gave positive feedback about the service and said that care workers respected their choices about the way care was delivered. A relative told us that “the service is 100% excellent I have no complaints.” All of the people who spoke with us indicated they would recommend the service to others.

People said they felt safe using this service and knew what to do if they had any concerns. They had been contacted by the provider before and immediately after the service had started. We were told people felt confident about contacting the provider if there were any issues.

We heard that people felt comfortable with the care workers and were able to ask them to complete additional tasks.

We found the provider did not have an effective system to regularly assess and monitor the quality of service that people receive and this could negatively impact on people’s experience of the service.

An adult social care and a pharmacy inspector carried out this inspection. We considered all the evidence we had gathered under the outcomes we inspected.

We used the information to answer the five 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?

This is a summary of what we found:

Is the service safe?

The service was safe. People received care that was safe because the provider had systems in place to minimise risks to people.

There was a robust recruitment process in place which minimised the risks of abuse to people who used the service. People told us they felt safe with the staff who supported them.

Risk assessments were carried out to ensure risks to people using the service, and to staff, were reduced.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

Is the service effective?

The service was effective. People received effective care and support which met their needs. Each person who used the service had their needs assessed to ensure the agency was able to meet their needs and expectations. One relative told us, “Before the service began we went through everything and developed the care plan together.”

Staff were well trained and had the skills and knowledge to effectively meet people’s needs.

Is the service caring?

The service was caring. People received care and support from staff who were caring and respectful. One person said, “All the girls who visit me are kind and sweet. They have become a bit like an extended family that you know you can always rely on.”

People’s privacy and dignity were respected and they were supported to maintain independent living skills.

Staff received training to enable them to provide appropriate care to people at the end of their lives. The provider liaised with appropriate health and social care professionals to make sure staff had the specific skills needed to meet people’s end of life needs.

Is the service responsive?

The service was responsive. People received a service which was personalised to the individual and responsive to changes in need or wishes.

Care plans were reviewed and up dated to make sure they were reflective of people’s changing needs and wishes.

People told us they would be comfortable to make a complaint and felt that any issues raised would be addressed.

Is the service well led?

The service was well led. The provider monitored the quality of the service provided by regular satisfaction surveys and spot checks on staff providing the service to people in their own homes. Shortfalls in the service were addressed to make sure improvements were made.

Staff told us the management team were always available to offer advice and support. There were regular team meetings and formal supervision sessions for staff to share good practice and information about the agency.

There was good communication between the agency and health and social care professionals to make sure people received appropriate care and support.