Passion Healthcare Limited improved from its previous Requires Improvement overall rating to Good, with the provider no longer in breach of Regulations 12 or 17. The Safe domain remained Requires Improvement due to gaps in risk assessments, a non-management staff reference, and an incomplete medicines policy, though no direct harm to people was identified.
Concerns (7)
moderate
Care planning
: “not all risks had been assessed. For example, one person who needed assistance with continence did not have a risk assessment in place”
moderateRecord keeping: “An assessment of health and safety of premises...had not included a plan to evacuate safely in the event of fire or whether there were smoke detectors installed”
minorMedication management: “The provider had a policy and procedure for the receipt, storage, administration and disposal of medicines...This had not included when to take as needed medicines.”
minorComplaints handling: “Complaints received since the last inspection had been investigated. Complainants had not received a written response to their complaints.”
minorGovernance: “Quality audits, surveys and reviews were carried out to drive improvement of the service. Some needed to follow up issues that had been raised.”
minorStaff competency: “one reference from a previous care employment had come from a work colleague, not management. This did not provide objective assessment of whether there were any concerns”
minorCommunication with families: “There had been a complaint about some staffs communication skills...some staff whose first language was not English, needed to have support to develop their English speaking skills”
Strengths
· People felt safe with staff and spoke warmly about their care, with strong person-centred relationships reported.
· Staff had good knowledge of people's needs, safeguarding procedures, and infection control practices.
· People received their medicines as prescribed and medicine audits were in place.
· Care plans included people's preferences, life histories and individual needs, supporting personalised care.
· Staff received induction, ongoing training, and supervision to support their development.
Quality-Statement breakdown (24)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standardsGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and controlGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Planning and promoting person-centred, high-quality care and opennessGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving careGood
well-led: Working in partnership with othersGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
A targeted inspection of Passion Healthcare Limited found no evidence of risk to people regarding staff recruitment, working hours or training, with safe recruitment, consistent staffing and robust induction in place. Ratings were not changed as only specific concerns were examined; previous ratings remain requires improvement (safe) and good (effective).
Strengths
· Safe recruitment practices including DBS checks, references and right to work checks, with risk assessments where only one reference was available
· Consistent, reliable staff team providing continuity of care with punctual visits and no late or missed calls reported
· Electronic rota system ensured staff worked within contracted hours with sufficient travel time between calls
· Robust induction and training including the Care Certificate and mandatory areas such as infection control, safeguarding and moving and handling
· Regular supervisions, spot checks and on-call support provided to staff to maintain competency
Quality-Statement breakdown (2)
safe: Staffing and recruitmentNot rated
effective: Staff support: induction, training, skills and experienceNot rated