This inspection took place on the 20 and 21 of November 2018 and was announced.

Nurseplus UK – Ashford is a domiciliary care agency. It provides personal care to adults who want to remain independent in their own home in the community. At the time of the inspection not everyone using the service received a 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 the inspection 130 people were receiving the regulated activity personal care. The service is also registered to provide treatment for disease, disorder or injury. However, no one was in receipt of nursing care when we inspected.

At the last inspection on 6 and 7 November 2017 the service was rated overall as requires improvement. Following this we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe, responsive and well-led to at least good. At this inspection we found that the rating remained requires improvement. This is the third consecutive time the service has been rated Requires Improvement.

There was a registered manager at 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. At the time of the inspection the registered manager was on planned leave and the deputy manager was the acting manager.

At the previous inspection we found a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Medicines were not always administered safely and the provider had failed to ensure care was provided in a safe way. At this inspection some improvements had been made to medicines management but there continued to be concerns relating to the recording of medicines and dating when bottles and creams were opened. We made a recommendation relating to the administration of medicines.

At the last inspection the service we found a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014, in that systems and processes had been not been consistently effective in identifying shortfalls and driving improvements in a timely way to ensure compliance and make sure people received a quality service. At this inspection, audits undertaken by the service had identified that there continued to be concerns relating to the recording of medicines and actions taken had not resolved all of the concerns. Further improvements were needed to be made and the service remained in breach There continued to be concerns about communication between the people who used the service and office staff.

Risks to people and from the environment were assessed and there was information for staff on how to lessen these risks. People were protected from the risk of infection and personal protection equipment such as aprons and gloves were available for staff and were used.

People were protected from abuse. Staff had a good understanding on what abuse was and reported concerns when they had them. Concerns were reported to the local authority and CQC and dealt with appropriately. Staff understood the principles of the Mental Capacity Act 2005 and supported people to make choices for themselves.

There were sufficient numbers of staff to cover care calls. Staff were recruited safety and the appropriate pre-employment checks had been carried out. Where things went wrong the service took action where this was needed. Staff had the skills, training and knowledge they needed to support people effectively. Staff received appropriate levels of supervision, underwen

We inspected Nurse Plus and Carer Plus (UK) Limited – Ashford on 06 and 07 November 2017 and the inspection was announced.

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community. It provides a service to older people and some younger adults.

Not everyone using Nurse Plus and Carer Plus (UK) Limited – Ashford receives a regulated activity; the Care Quality Commission 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.

Nurse Plus and Carer Plus (UK) Limited Ashford provide care and support to people in their own homes. The service is registered to provide personal care and treatment of disease, disorder or injury. At the time of the inspection there were approximately 200 people receiving support with their personal care and none in receipt of treatment of disease, disorder or injury. The service undertakes visits to provide care and support to people in Ashford, Tenterden, Romney Marsh and surrounding areas. The service can also provide 24 hour support to people.

The service is run by a registered manager. Their registration had been confirmed the week before our inspection. They were not present at the inspection as they were on leave. A registered manager is a person who has registered with 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.

At the last comprehensive inspection in November 2016 the overall rating for the service was Requires Improvement. Four breaches of regulations of the Health and Social Care Act 2008 (Regulated Activities) 2014 were identified. The provider had failed to have proper and safe management of medicines, mitigate risks to people’s health and safety, mitigate risks in infection control, ensure people were treated with dignity and respect, ensure care plans reflected people’s preferences and ensure systems and processes were operated effectively.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when, to improve the key questions safe, effective, caring, responsive and well led to at least Good.

At this inspection we found that some improvements had been made and three of the breaches had been met. However, checks on the quality of the service continued not to identify and address shortfalls in the service. Further improvements were required in relation to the recording of medicines and responding to people’s concerns.

Checks and audits had been completed but were not consistently effective in driving improvements in a timely way to ensure compliance and make sure people received a quality service.

People’s medicines were not consistently managed safely. Staff did not complete medicines records correctly. We have made a recommendation about the management and recording of some medicines.

People knew how to complain and the provider followed their policy to handle complaints. Some people told us they had raised concerns in the past and they felt the provider had listened but had not been effective in ensuring the same issues did not arise again.

Communication between the care staff and the office and between the office and people was inconsistent. Some staff had noted that there had been improvements since the new manager had been in place.

People told us they felt safe in the company of the care staff. Action had been taken and risks to people were now assessed, managed and reviewed. People were now protected against the risk of infection. People were protected from the risks of discrimination, abuse and avoidable harm.

People were supported by sufficient s

Nurse Plus and Carer Plus (UK) Limited Ashford provide care and support to people in their own homes. The service is provided to mainly older people and some younger adults. The service is registered to provide personal care and treatment of disease, disorder or injury. At the time of the inspection there were approximately 360 people receiving support with their personal care and none in receipt of treatment of disease, disorder or injury. The service undertakes visits to provide care and support to people in Ashford, Tenterden, Romney Marsh and surrounding areas. The service can also provide 24 hour support to people.

The service is run by an established registered manager. 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 their medicines were handled safely. However there were shortfalls in some medicine records and a lack of guidance about some areas of medicine management.

Risks associated with people’s care and support had been identified, but not all actions in place were recorded on risk assessments to help ensure people remained safe. People were not fully protected against the risk of infections as there were inconsistencies in staffs use of personal protective equipment.

People were involved in the initial assessment and the planning of their care and support and some had chosen to involve their relatives as well. Most care plans were detailed reflecting people’s preferred routines. However not all tasks undertaken by staff were always incorporated into the care plan and not all care plans were up to date reflecting people’s current care and support. People told us their independence was encouraged wherever possible, but this was not always supported by the care plan.

People felt most staff were caring and respected their privacy and dignity. However people gave examples where they felt this was not the case.

There were audits and systems in place to monitor that the service ran efficiently. These had been effective in identifying the shortfalls highlighted during this inspection, but were not effective in driving improvements in a timely way. People felt the timing of their visits, continuity of staff that visited them and communication within the service were all areas that required improvement.

New staff underwent an induction programme, which included relevant training and shadowing experienced staff, until they were competent to work on their own. Staff received training appropriate to their role and a high percentage of the staff team had gained qualifications in health and social care or were working towards this.

People felt safe using the service and when staff were in their homes. The service had safeguarding procedures in place and staff had received training in these. Staff demonstrated an understanding of what constituted abuse and how to report any concerns in order to keep people safe.

People told us their consent was gained at each visit. People were supported to make their own decisions and choices. No one was subject to an order of the Court of Protection although some people had made Lasting Power of Attorney arrangements and others had a Do Not Attempt Resuscitation (DNAR) in place. Some people chose to be supported by family members when making decisions. The Mental Capacity Act provides the legal framework to assess people’s capacity to make certain decisions, at a certain time. When people are assessed as not having the capacity to make a decision, a best interest decision is made involving people who know the person well and other professionals, where relevant. The registered manager understood this process.

People were supported to maintain good health and they told us staff were