This inspection took place on 6 and 7 December 2017 and was announced. The provider was given 48 hours' notice because we wanted to make sure the registered manager and staff would be available to speak with us.

J.M. Healthcare is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community. Not everyone using J.M. Healthcare receives regulated activity; CQC only inspects the service being received by people provided with ‘personal care’; help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided. At the time of this inspection, 60 people were receiving personal care from the service.

The service had 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.

J.M. Healthcare was previously inspected on 16 December 2016. At that inspection, we identified breaches of the legal requirements. These related to the management of medicines and the accuracy of records regarding the care people were receiving. The service was rated as 'Requires Improvement'. Following that inspection, the provider contacted us outlining the steps they would take to meet the relevant legal requirements.

At this inspection December 2017, we found improvements had been made in the way the service managed people’s medicines; risks associated with people’s care and support were now being identified, and regular reviews of people’s care were now taking place. However, further improvements were still required. We looked at the care and support plans for eight people with varying healthcare needs. We also met with them to review how well the service was meeting their needs and minimising risks to their health, safety and well-being. We found each person’s care plan contained a risk management plan that identified risks to their health and safety. Whilst some were detailed and contained specific guidance for staff to follow others were not and lacked guidance for staff to demonstrate that risks were being effectively managed and/or mitigated.

We have made a recommendation the provider and registered manager ensure the risks associated with people’s care are documented and kept under review.

At our inspection in December 2016, we had found reviews of peoples care were not taking place and the information contained within people’s records was focused on tasks and was not person centred. At this inspection, we found although some improvements had been made, improvements were still required.

We looked at the care and support plans for the eight people. We found, two of eight care plan we reviewed did not contain information about the person’s hobbies or interest that would enable and support care staff to engage meaningfully with this people. We discussed what we found with the registered manager who agreed the information contained within people’s care and support plans was not as person centred it could be.

We have made a recommendation the provider seek advice and guidance from a reputable source in developing care and support plans that are person centred.

We looked at the services’ quality assurance and governance systems to ensure procedures were in place to assess, monitor, and improve the quality of the services provided. These included a range of audits and spot checks. We found that although some systems were working well others were not. Quality assurance systems had not fully identified that some people’s risk management plans lacked guidance for staff to demonstrate that risks were being effectively managed or that some people’s care and support plans were not as person centred as they could be.

We have made a rec

J.M. Healthcare provides personal care and support to approximately sixty three people in and around Ivybridge, Kingsbridge, Salcombe and Newton Abbott. At the time of our inspection a team of thirty six staff were operating from the main office in Ivybridge.

The service is required to have a registered manager in post. At the time of our inspection there was not 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. A manager had been working in the service since May 2016. An application for the post of registered manager had not been submitted to the commission.

Staffing levels were being monitored and recruitment was still in place. Staff told us, “It’s been a difficult few months but things seem to be getting better now” and “We have all had to do extra to cover the gaps.” The service used a mobile phone based call monitoring system to ensure all planned care visits were provided each day. Contracted hours were being met but there were times when staff were late for calls or did not arrive. Staff were expected to call the office if there were delays. One staff member said, “Sometimes we can’t get through, it can be a problem.” The inspector noted that on the day of the inspection engineers were visiting the service to arrange installation of an extra line into the office to improve communication channels. Comments from people during a recent survey included concerns that staff had been late for calls or had arrived on the wrong day.

We have made a recommendation for the service to improve its communication system.

Care plans were in place but in most instances information was dated. For example, one file had an assessment from 2015 but no other evidence of reviews having taken place. Assessments from service commissioners were in place on two files seen but they were dated from 2012 and 2013. In one instance when visiting a person’s home the folder contained the original commissioner’s assessment from 2012. The most recent agency assessment was dated August 2015. There was no evidence of reviews taking place recording any changes in the person’s needs. The person told us they had been admitted to hospital since the latest assessment but there was no information to show care needs had changed or were being responded to.

Risk assessments were in place on all files seen. They covered areas of personal care, diet, health and safety, although where risk had been identified there was a brief overview but no plan of action to show how the risk would be managed. In one instance a stair lift had been fitted recently but the person’s risk assessment had not been updated to show the level of risk to the person using it.

Medicines were not always being recorded in people’s homes. Some records showed there were gaps where it could not be confirmed if a medicine had been administered. In other records staff were using letters from the index at the bottom of the medicine record. For example (D) which denoted dispensed, however on other days the staff member signed their signature to denote it had been administered. Staff told us (d) stood for medicines left for the person to take themselves after the carer had left the service. Some medicine records had recently been audited. One showed staff being prompted to sign for all medicines given. However there were still gaps where staff were not always signing. This meant people had the potential to be at risk because staff did not know if the medicine had been administered or not.

There were weekly meetings between the manager and directors to review the operational issues. The meetings looked at the use of staff hours and field managers had been designated eighty per cent of the

At the time of our inspection the service was providing care to around 20 people. We visited the agency's office, looked at five people’s care plans, spoke with nine people on the telephone and visited two people in their own homes to discuss the care they received. We also spoke with three staff members about their employment.

People we spoke with told us the agency met their needs. One person told us the agency staff were like "Family" to them. Others spoke well of the kindness, friendliness and skills of the staff who attended them.

However, we found that staff training systems were not comprehensive enough to ensure that staff could competently meet people's needs for care. As an example we found that staff did not have training in first aid, and many did not have updated training in areas such as health and safety, infection control or the mental capacity act. Supervision and staff support systems had been inconsistent, but were being established.

We found some other systems were also inconsistent or not audited regularly.

Staff we spoke with told us that they enjoyed working for the agency and felt well supported. They told us they could contact the office or a senior at any time for advice or support if they needed this.

We inspected JM Healthcare in June 2013 and found improvements were required to aspects of the care people received, the training staff received and to the monitoring of service provision. The provider sent us an action plan detailing the improvements they intended to make in the above areas. We met with the new registered manager on the 6th January to discuss the progress of the action plan and looked at four care records. On the 7th January we spoke with four people on the telephone who used the service.

People's needs were assessed prior to JM Healthcare providing support to ensure people's needs could be met.

Staff received an induction when they started work for JM Healthcare and one to one meetings with the registered manager which supported them in their role.

We found an improved system to monitor the quality of service provision was in place and regular reviews of people's care had taken place.