Passion Recruitment Agency remained in breach of Regulations 12 and 17 at this focused inspection, with ongoing failures in risk assessment guidance, post-incident care plan updates, medication management, and audit robustness. The service improved to Good for Effective, with positive recruitment practices, staff training, and person-centred care noted as strengths.
Concerns (5)
criticalCare planning: “when a fall had occurred, people's care plans and risk assessments were not always updated to reflect the circumstances of the fall and any impact on how care was provided.”
critical
Medication management
: “staff member had administered an over-the-counter medicines which had not been prescribed and was not identified in the care plan. The possible interactions this medicine could have with the prescribed medicines had not been identified.”
criticalGovernance: “audits of both these documents had not identified the discrepancy between the information...checks carried out were not robust enough to indicate where actions were required.”
moderateIncident learning: “incident and accident record identified this person should not be left on their own...but this was not achievable as the staff member was not able to supervise the person all the time. There were no other actions identified.”
moderateRecord keeping: “a staff member had completed the MAR indicating they had administered the medicines at a specific time. A different staff member had completed the records of care stating they had given these medicines.”
Strengths
· Relatives felt their family members were safe when receiving care at home and staff turned up on time.
· Provider made improvements to recruitment processes including DBS checks, verified references and right-to-work checks.
· Staff completed appropriate training including first aid, moving and handling, diabetes, health and safety and end of life care.
· Care was person-centred with care plans including social history, communication support needs and individual preferences.
· Staff demonstrated good understanding of Mental Capacity Act principles and consent.
Quality-Statement breakdown (14)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
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: Ensuring consent to care and treatment in line with law and guidanceGood
well-led: Continuous learning and improving careRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Engaging and involving people using the service, promoting a positive person-centred cultureGood
Passion Recruitment Agency was rated Requires Improvement overall at its first inspection in March 2022, with regulatory breaches identified in safe care and treatment (Reg 12), staffing and training (Reg 18), fit and proper persons employed (Reg 19), and good governance (Reg 17). While the single service user reported positive experiences and care workers demonstrated respectful practice, the provider failed to ensure robust recruitment checks, adequate staff training, care plan currency, and quality assurance processes.
Concerns (9)
criticalStaffing levels: “The provider did not always follow their recruitment procedures to ensure appropriate checks had been carried out on applicants to ensure they were suitable for the care worker role.”
criticalStaff training: “The provider confirmed they had not completed any training. Both care workers had been in post since July 2020.”
criticalGovernance: “The provider did not have robust audits and quality assurance processes to enable them to assess and identify where action was required.”
criticalLeadership: “The registered manager had not been actively involved with the service for around five months.”
moderateSupervision / appraisal: “There were no records of any supervision or appraisals being carried out for all three care workers.”
moderateCare planning: “The care plan had not been reviewed since September 2020 and still included care activities which either had not been provided or were no longer required.”
moderateRecord keeping: “The number of visits per day increased. The care plan had not been updated to show this and provide information for care workers on what support the person required.”
moderateIncident learning: “There was no information on how incidents and accidents relating to people using the service should be recorded, investigated and any lessons learned identified.”
moderateSafeguarding: “The provider had not developed COVID-19 risk assessments or risk management plans for people receiving care or for care workers.”
Strengths
· The person receiving support felt safe and was happy with the care provided, describing care workers as competent with good timekeeping.
· Care workers demonstrated understanding of privacy and dignity, respecting personal space, confidentiality and communication preferences.
· The provider followed MCA principles, completing mental capacity assessments as part of initial needs assessments.
· Care plans identified nutritional needs, healthcare contacts, oral health care, and communication requirements including preferred language.
· Care workers were provided with adequate PPE and confirmed sufficient supplies were available for visits.
Quality-Statement breakdown (21)
safe: Staffing and recruitmentRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionGood
safe: Systems and processes to safeguard people from the risk of abuseGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law
Good
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
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: Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffGood