The inspection activity commenced on the 31January 2018 and completed on 16 February 2018 and was announced. We inspected the office location on 31 January, received additional information from the provider on 7 February and obtained feedback from staff and people who used the service on 7 and 16 February.

We last inspected the service on 17 July 2017 and found there were three breaches of regulation in relation to regulation 13 safe recruitment processes, regulation 17 good governance and regulation 19 fit and proper persons employed. The provider submitted an improvement action plan telling us how they would make the required improvements. At this inspection, we found the provider had made the required improvements and were meeting the standards. However, one area still required improvement. This was in relation to consistency in record keeping.

Overall, the service was well managed and people were happy with the service they received. However, records were not always completed in a timely or effective way. For example recruitment records in some cases lacked detail and were not as robust as they could have been. Staff support records lacked structure. Quality monitoring audits were in place but would benefit from further development to ensure actions were signed off to improve the effectiveness.

This service is a domiciliary care agency. It provides personal care to people living in their own homes in the community. Compassionate Herts Ltd is registered to provide a service for people, older people, people who live with dementia, or people with a physical and or learning disability At the time of this inspection Compassionate Herts Care supported seven people with personal care.

There was a registered manager for the service. 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.

People felt safe receiving support from Compassionate Herts LTD. Staff understood how to keep people safe. People were kept safe because risks were managed and mitigated effectively.

Recruitment processes were not always as robust as they could have been. We discussed this with the provider and registered manager. They took immediate action to review their processes. This helped to ensure that staff were of good character and suitable for the roles they performed. Sufficient staff were employed to meet people’s needs in a timely way.

Staff were supported through regular individual supervision, observed practice and team meetings. Staff had the knowledge and skills necessary to meet people's individual needs and wishes. The registered manager followed the principles of the Mental Capacity Act 2005 (MCA). People were asked to consent to their support. People were encouraged to eat and drink sufficient amounts to maintain their health and well-being and were assisted to access healthcare professionals promptly when needed.

People and their relatives were positive about the staff who supported them. They told us staff were kind and caring. Staff knew people well and people had been involved in the development, review and planning of their care where they were able.

The provider had systems in place to obtain feedback from people who used the service and their relatives. People and their relatives felt comfortable approaching staff or the registered manager to raise anything that concerned them and were confident their concerns would be taken seriously.

People felt the service operated in an open and transparent way. Staff were well supported and were proud to be working for Compassionate Herts Care. The registered manager demonstrated an in-depth knowledge of the staff team, and people who used the service.

The inspection took place on 18 and 19 July 2017. The inspection was announced to make sure that the Provider who was also the registered manager was available to support the inspection. It was the first inspection since the service was registered on 16 September 2016.

Compassionate Herts Ltd is a small domiciliary care service which provides personal care and support to people in their own homes. The service was supporting eight people at the time of our inspection.

There was a Provider who was also the registered manager in place who was also the provider. A Provider who was also the 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 and associated Regulations about how the service is run.

The provider told us that staff had not received safeguarding training yet and records confirmed this to be the case. This could place people at risk of abuse as staff would not have the skills and knowledge to identify and report potential abuse. There was a safeguarding policy in place and we saw that a safeguarding concern that had been raised had been properly recorded and investigated by the local safeguarding authority.

We saw that risk assessments had been completed. The risk assessments contained adequate information but could be more detailed to help staff mitigate identified risks effectively.

Consent to care had been obtained and was recorded in people’s care plans. The Provider who was also the registered manager had completed a train the trainer course to enable them to train staff in the topic of Mental Capacity Assessments (MCA) . However staff had not received training and two people who were being supported who the Provider who was also the registered manager told us had a diagnosis of dementia and lacked capacity to make decisions about their care and support had not had their capacity assessed in accordance with the Mental Capacity Act (2005) (MCA).

The provider told us that staff had received first aid training along with moving and handling training. and the MCA and we saw records to confirm this along with some medicine competency checks.

We found that the recruitment process was not robust and pre-employment checks had not been consistently completed in accordance with the provider’s own recruitment process in particular in respect of incomplete application forms, exploring gaps in employment histories and obtaining and validating references.

There were some quality assurance systems in place. However these were not effective in identifying the shortfalls we identified as part of the inspection. Staff had not received induction or on-going or refresher training and support arrangements were inconsistent. We suggested that the Provider who was also the registered manager may want to consider approaching an organisation to help support them with addressing the shortfalls.

There was a complaints policy and procedure in place. The Provider who was also the registered manager told us they had received one complaint and we saw this had been appropriately investigated and responded to.

The Provider who was also the registered manager told us they planned to send a survey to people who used the service to obtain feedback and this was in progress at the time of our inspection. The information had not been analysed at the time of our inspection, so we could not assess the effectiveness of the process.