This inspection took place on 22, 23 and 24 January 2018 and was announced.

At the last inspection on 3 May 16 we found breaches of the regulations, including Regulation 9 Person centred care, Regulation 12 Safe care and treatment and Regulation 17 Good governance. The service was rated requires improvements overall.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve person centred care, safe care and treatment and governance to at least good.

This small domiciliary care agency was providing personal care to people living in their own homes in the community. It provided a service to older adults and people with a learning disability. The number of people receiving a service had reduced from 19 to 10 people since our last inspection. There was a registered manager in post at the time of the inspection who explained the provider was reducing the number of service users within the service in preparation for moving to another premises/area.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. 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.

During this inspection we found continued breaches of the regulations. Risks were not always being identified or mitigated for people using the service, there was minimal information about people seen in their care plans and quality assurance systems were not robust. You can see what action we told the provider to take at the back of the full version of the report.

On our last inspection we found there was not enough person centred information about people receiving a service. We found on this inspection people living with dementia had no person centred care plan and only one person out of 10 had an "All About Me" care plan in place. An “All About Me” care plan is written to provide important information about the person. The provider had not met their legal responsibility and remained in breach of regulation; person centred care.

We found on this inspection the registered manager had conducted a survey but had not undertaken any other audits of their systems. For example, there had been no audits of medication administration records and we had not been provided with a statutory notification when appropriate. The provider had not met the legal requirements and remained in breach of regulation, Good Governance.

On our last inspection medicine management systems were not safe. Medication administration record sheets (MARS) were checked in people’s homes who we visited. Two out of the four people we visited in their own homes were being supported with their prescribed medicines. Both people’s MARS had gaps or a symbol X with no code to denote what this was referring to. We found other risks were not being identified or mitigated for people receiving the service. For example, emergency contingency plans were not clearly written in care plans for people. The provider had not met actions from the last inspection and remained in breach of safe care and treatment.

Mandatory training (which is essential training) being offered for staff was minimal and only included moving and handling training provided by the registered manager who was an approved trainer.

Staff had undertaken medicines awareness as part of the Care Certificate but had not completed a specific training course in safe medicine management. Staff competency checks were not seen in staff files so we could not be sure staff had been assessed as competent.

We were concerned there were not enough staff trained with the necessary skills to provide a good standard of care for people.

Care plans contained a bullet pointed list of tasks people needed support with in the morning, lunch, tea and evening with no spec

This inspection was announced and took place on the 03 May 2016.

The agency was previously inspected in September 2013 when it was found to be meeting all the regulatory requirements which were inspected at that time.

Caring Hands Cheshire is a domiciliary care agency provided by Caring Hands Cheshire Ltd. The service is coordinated from premises in Church Street, Runcorn and operates across the Halton, Runcorn, Warrington and Cheshire areas. The service was providing the regulated activity ‘personal care’ to approximately 19 people with a broad spectrum of needs at the time of our inspection.

At the time of the inspection there was a registered manager at Caring Hands Cheshire Limited. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. 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.

The registered manager was present during the day of our inspection and engaged positively in the inspection process, together with another member of the office management team.

During this inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take as the back of the full version of the report.

We found that records relating to accidents and incidents and missed visits could not be located to enable the inspection team to obtain an overview of this key information.

We also found no evidence that assessment of needs had been undertaken by the provider for people using the service.

People spoken with confirmed the service they received was caring and that they were treated with respect and dignity by the agency’s staff.

Systems had been developed to seek the views of people using the service, ensure complaints were listened to and acted upon and to safeguard vulnerable people from abuse. No formal complaints were received from the people using the service during our visit however some people raised concern regarding the arrival times of staff.

Recruitment procedures had been established to help protect people using the service against the risks of unsuitable staff gaining access to work with vulnerable adults.

Staff had access to training relevant to their roles and responsibilities and to supervision and team meetings. This helped to ensure they received the necessary support and direction in their roles.

We spoke with four people who were provided with support from the service and two relatives.

They made mixed comments about the service but gave overall positive comments about the care and support provided such as: “The staff that come out give 10 out of 10 there’s nothing wrong with the staff” and “I’m quite happy with the service”; “On the whole it’s absolutely superb, above and beyond, they are brilliant with my relative” and “Everything seems ok, the staff are like my friends.”

Some of the people we spoke with made various suggestions regarding what they would like to see improved with the management of the service such as: having regular staff teams so they had the stability of knowing what staff were attending to them; to have staff arrive on time; to have regular reviews; to not have male staff attend to female service users and to have basic training in nutrition and how to cook meals.

We contacted the local authority contracts and monitoring team for Halton who shared a detailed report of a visit they carried out to the service in October. Overall their report was positive with some areas identified for further review and an action plan had been developed.

The 3 people spoken with were generally happy with the service provided. Some comments made were:-

"The service is great, the staff are very kind, I have no faults."

"The girls do what I need them to and they are good company."

"The service is mostly okay. There have been some staff who do not seem as experienced as others."

The 3 people spoken with said they all had access to their care plans and said they are getting the care they need. They described the staff as polite and respectful. All said that the carers prompt them to take their medication where this support is needed. All said that they generally have the same carers, which provides continuity. They said staff are generally punctual and stay for the length of time they are required to. They said that staff wear their identity badges and uniforms and are professional in their manner.

The 3 people spoken with had been asked to complete a survey about their views of the service. They were aware of how to make any complaints known.

During our visits to people using the service we observed people being treated in a friendly and dignified manner by the carers.

A health professional spoken with reported no issues of concern around the agency's practices with regards to the management of medication for the people whose records we looked at. They said that staff have always been polite and helpful towards the people using the service. They have always appeared professional and been seen to wear a uniform and identification badge.

Monitoring visits were undertaken by Halton Borough Council on 2nd and 3rd June 2011 and 23 July 2011. During their visit in June 2011 they spoke with 4 people using the service and their relatives and found they were satisfied with the service provided. Some raised issues about staff arriving late and 1 service user and their relative said staff rarely complete all the tasks required but that they were generally satisfied.

Halton Borough Council reported that in general there were robust practices around recruitment but that some improvements needed to be made to ensure references provide a better safeguard. They spoke to 4 staff who were all very positive about working for the agency and the support they receive. All said that they had received induction and refresher training.

On their most recent visit and on previous visits Halton Borough Council found that staff are not staying for the length of time they are supposed to and are not always reporting this to the management team.

People being supported by the service told us they were very happy with the support provided by the staff team. They made various comments such as:

“Staff remind me it’s my home when I ask questions and they always do what I ask”; “I can’t praise Caring Hands enough” and “They always try to help.”

Care plans were detailed and provided alot of information to show how peoples needs and requests were being met.

Staff were positive about working for the service. They were well supported with their training needs to be able to meet peoples' individual needs. They had been supported with a lot of training to help them with their work.