Passion 4 Care

Updated 1 June 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection team consisted of one inspector, one assistant inspector and one Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

We gave the provider 24 hours' notice of the inspection. This was because we needed to be sure that the provider or registered manager would be in the office to support the inspection.

Inspection activity started on 11 February 2022 and ended on 4 March 2022. We visited the office location on 24 and 25 February 2022. Calls were made to people and staff on 11 and 14 February. Feedback was given to the registered manager on 4 March 2022.

What we did before the inspection

We reviewed information we had received about the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection. We used all this information to plan our inspection.

During the inspection

We spoke with five people using the service and nine relatives. We spoke with 11 members of staff, including the provider, registered manager and care workers. We looked at six staff files in relation to recruitment and staff supervision. We looked at 10 people’s care records, including their medication records. We reviewed a variety of records including records relating to the management of the service.

After the inspection

We continued to seek clarification from the provider to validate the evidence found. We looked at training data and quality assurance records. The provider gave verbal assurances they would be taking steps to address the issues found during the inspection.

Updated 1 June 2022

About the service

Passion 4 Care is a care at home service providing personal care for 100 people at the time of inspection. The service provides support to people who are living with dementia, mental health or a physical disability. The service supports people in their own homes.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided.

People’s experience of using this service and what we found

Staff frequently arrived late to people’s care call, and, on occasion people had experienced missed calls. Some people’s care plans, including their medication care plans required clearer guidance for staff to follow to ensure they were providing appropriate support. Staff did not always complete medication records correctly but there was no direct impact on people using the service. Recruitment records were not robust. Staff files contained incomplete application forms and gaps in their employment history. The provider undertook audits of the service but we found the audits had not highlighted the issues found during the inspection.

Steps had been taken to protect people from the risk of infection. Staff had the required skills and training to support people safely. People were supported to eat and drink. Staff treated people with kindness and respect. People were involved in making decisions about their care. Staff felt supported by the registered manager. The registered manager collected feedback from people and their relatives about the care people received. The provider worked with external agencies and professionals to ensure people received the support they needed.

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

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 28 June 2019 and this is the first inspection.

Why we inspected

This was a planned inspection.

We have found evidence that the provider needs to make improvements.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified a breach in relation to the overall governance of the service at this inspection.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.