This inspection visit took place on 5 June 2018 and was unannounced due to concerns we received.

We made telephone calls to people who used the service, their relatives, staff and other professionals to obtain their views. These calls took place on the 6, 7, 8 and 12 June 2018.

European Nursing Agency, also known as ENA, provides 24-hour care by way of live in care workers who support and provide personal care for people in their own homes. At the time of our inspection there were 72 people using the service.

At the time of our inspection the provider had applied to add treatment of disease, disorder and injury to their registration but this application was still being assessed. The provider was registered to provide personal care to people.

The service did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 provider had completed an application to become the registered manager with CQC before the inspection took place.

At this inspection we found a breach of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to good governance. The provider had failed to operate effective quality assurance and auditing systems.

There was not enough staff in the office to ensure people and staff received the appropriate support.

Care plans we looked at lacked risk assessments and appropriate guidance around risks.

Staff helped and supported people to take their medicines safely. Staff received training in safe administration of medicines and knew how to make sure people received their medicines safely. However, we found that the providers monitoring systems were not adequate to ensure that medicine practices were safe.

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People felt safe using the service. However, although accidents and incidents were reported these were not always investigated and reported to CQC when required.

Staff received training to enable them to carry out their role effectively and safely. However, we noted that some staff training was overdue.

Staff sought people's consent to care. People received support to access healthcare appointments if needed.

People and their relatives told us they were satisfied with the staff that provided their care. Staff members often took the time to have a chat and support people with their needs.

People were fully involved in making decisions about their own care. People felt staff treated them with dignity and respect.

People and their relatives told us they had been involved in developing people's care plans and felt that staff listened to them.

People and relatives knew how to raise concerns and felt they would be supported if they needed to complain.

This inspection took place on 22 and 23 February and 6 March 2017. This was an announced inspection where we gave the provider 48 hours' notice because we needed to ensure someone would be available to assist us with the inspection.

We brought forward this inspection due to concerns raised with us. These concerns were about the recruitment and support of staff and the lack of reporting to the commission of safeguarding. However, we found the provider had acted on the concerns raised and clarified recruitment and support of staff as well as procedures around reporting safeguarding.

European Nursing Agency (ENA) provides live-in personal care and support to people, some of whom have complex physical needs, in their own homes as well as providing hourly personal care day visits. At the time of the inspection European Nursing Agency was supporting 106 people.

The service had a manager who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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. In this instance the registered manager was also the provider.

We found further developments were needed in the assessments for activities or areas that could pose a risk to people as they were not always detailed or contained sufficient information to inform staff how to manage situations. However, staff were clear on their role and how to keep people safe.

Whilst we found there were systems in place to review the quality of the service, these were not always consistent as some of the care plans had not been reviewed and contained information that was out of date.

People told us they felt safe and were confident in staff abilities to support them. Staff were trained and supported to deliver good care. Safe and effective recruitment practices were followed to ensure that all staff were suitably qualified and experienced. There were sufficient staff with a on call team of care staff to cover emergencies.

People received care that was personalised to their needs. They were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.

People were treated with dignity and respect and were involved in planning their care.

The registered manager and staff promoted an open inclusive culture focused on providing a personalised service for each person. However, systems in place to monitor the quality of the service were not always consistent.

We carried out an inspection of European Nursing Agency on 12, 18 and 19th April 2016. This was an announced inspection where we gave the provider 24 hours’ notice because we needed to ensure someone would be available to speak with us.

European Nursing Agency provides live-in personal care and support to people, some of whom have complex physical needs, in their own homes. The agency also provides visits people in their own homes to provide personal care. At the time of the inspection European Nursing Agency was supporting 110 people.

We last inspected the service on 19 June 2013 and found the provider was meeting the required standards at that time.

There was a registered manager in post. 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 told us they received safe care, which was reliable. European Nursing Agency assign live- in carers for an average three month period, after which they have a break and on occasions return to the same placement if all parties are in agreement. People were given the time they needed to ensure their care needs were met.

People were protected from avoidable harm and staff knew what to do if they suspected abuse. Risks to people were assessed and risk management plans were in place and being further developed.

Staff had the skills and training they needed to deliver effective care. All of the staff we spoke with told us they were supported by the management team who were developing ways of live in staff to have peer meetings.

The service was working to the principles of the Mental Capacity Act 2005 and care staff supported people to make their own choices about their care.

There were robust recruitment processes which helped to ensure that staff members employed to support people were fit to do so. Staff knew their roles and responsibilities and were knowledgeable about the risks of abuse and reporting procedures.

People were supported with a range of services which enabled them to continue to live in their own homes safely. People and relatives told us they had been involved in the assessment and planning of the care and support provided and that the service responded to changes in people’s needs.

All the care staff who dealt with people’s medicines had received medicine management training and were clear about their role in managing medicines safely.

People told us the service was well managed and they felt they could approach the manager and care coordinators with any concern and they would be dealt with. Care staff told us they enjoyed working for the service and received good training.

Systems were in place to monitor the quality of the service provided to help ensure people received safe, effective, care and support.

During our inspection we visited the agency's office and the homes of two people who used the service on 13 June 2013. On 19 June 2013 we spoke to 14 people who used the service and five care workers on the telephone. People told us that they and their relatives had been involved in the discussions as to the care that they needed and were involved in regular reviews of their needs with their care co-ordinator. One person told us that their care co-ordinator "...checks if everything is okay or if anything wants to change." People told us that the care workers treated them with dignity and respect at all times.

People told us that they were happy with the quality of the care that was provided. One person told us, "They are excellent." We saw that people's care plans were very detailed and personalised and were supported by detailed assessments that identified possible risks to people, such as moving and handling and nutrition.

We spoke with seven care workers who were able to demonstrate that they had a good understanding of what constituted abuse and the procedure for reporting safeguarding issues. Records showed that new staff members had started work only after a full and satisfactory criminal records check had been received.

People we spoke with told us that they were very satisfied with the quality of the care provided by the service. They said that they had regular visits from their care co-ordinators who discussed the quality of the service provided.