Passion 4 Care was rated Requires Improvement overall at this first inspection, with late and missed calls, weak medication and care plan records, and non-robust recruitment and governance leading to a breach of Regulation 17. Staff were nonetheless found to be kind, well-trained and effective in supporting people's needs, with effective and caring domains rated Good.
Concerns (10)
critical
Missed or late visits
: “Most relatives we spoke with told us their relative frequently received late calls and on occasion had experienced missed calls.”
criticalGovernance: “The provider's quality assurance systems and processes were not sufficiently robust to address the shortfalls we found during the inspection.”
criticalSafeguarding: “The registered manager did not always notify us about potential safeguarding incidents.”
moderateMedication management: “Medication care plans did not always contain detailed information about the medication or specific guidance about how the medication should be administered.”
moderateRecord keeping: “three people's medication care plans and medication administration records (MAR) contained conflicting information”
moderateCare planning: “Care plans did not always contain enough information about people's needs and preferences.”
moderateIncident learning: “Trends in incidents and accidents had not been explored in detail. This meant opportunities to prevent reoccurrence an improve safety were missed.”
moderateOther: “application forms contained missing information, interview records were not always completed, school leaving dates were not always included, and gaps in employment history had not been explored”
minorLeadership: “Most relatives were unclear about who the registered manager was. One person told us, 'I don't know who the registered manager is, and I haven't met them.'”
minorEnd-of-life care: “Not all care plans outlined peoples end of life wishes.”
Strengths
· Staff treated people with kindness, respect, dignity and promoted independence
· Staff received training tailored to people's needs, with regular supervisions, appraisals and spot checks
· People were supported to eat and drink, with dietary needs reflected in care plans
· Staff understood and applied the principles of the Mental Capacity Act
· Service worked effectively with external healthcare professionals such as district nurses, GPs and occupational therapists
Quality-Statement breakdown (20)
safe: Assessing risk, safety monitoring and management; Preventing and controlling infectionNot rated
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongNot rated
safe: Using medicines safelyNot rated
safe: Staffing and recruitmentNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies; Supporting people to live healthier lives, access healthcare services and supportNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empowering; Engaging and involving people using the service, the public and staffNot rated
well-led: How the provider understands and acts on the duty of candourNot rated
well-led: Working in partnership with othersNot rated