The inspection of Premier Nursing Services was on 12 September 2018 and was announced. We gave the provider two days’ notice of the inspection. This ensured that staff were available in the office and people were prepared, to receive a telephone call, from the inspection team.

Premier Nursing Services 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. At the time of the inspection the service was providing care to 22 people who lived in, or around Arundel. This service provided both planned visits to people’s home and a live-in service.

At the last inspection, on 11 May 2017, Premier Nursing Services was rated as Requires Improvement. We had identified concerns relating to staff supervision and appraisals. We also found that systems, to check the effectiveness and safety of the service, were not always completed fully, or in a consistent manner. At the inspection before this, on 13 and 15 April 2015, we had identified concerns about the safe care and treatment of service users, and the oversight of the provider. More specifically, there had been concerns about risk assessments and the systems they had in place, for checking new staff, to ensure they were suitable for the job. We had also identified concerns relating to staff training. The concerns, relating to risk assessments and the suitability and training of staff, had been addressed at the inspection on the 11 May 2017. However, the oversight of the service had continued to require improvement.

Since the last inspection the provider had established a robust system, for ensuring staff received appropriate levels of support, with regular supervisions and appraisals. They had improved their method of reviewing the care people received, to ensure it was consistent and of an appropriate standard. However, processes to ensure the service was safe, and care was given in a consistent manner, continues to require improvement.

It is a requirement for providers to display their previous CQC rating in their registered premises and on their website. We reviewed the website, prior to the inspection, and the rating was not displayed. This was discussed with the provider, during the inspection. The provider has since ensured the rating is displayed, both within their office and on their website.

Not all care plans contained person-centred information. Some care plans were lacking specific details about the care people required.

There was a system for audits and quality reviews in place. However, documentation was not always robust, with omissions in the medication administration records and a variable amount of person-centred information in some care records. The quality assurance processes had not identified or corrected this.

Staff were involved in the management of medicines. Medicines were given appropriately, although we found omissions in some of the medication administration records. During the inspection the administrator devised a medicine audit and devised a plan to incorporate this into their routine practice.

At the time of our inspection 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. On the day of the inspection the registered manager was away but we have spoken to them since the inspection.

People’s care need were assessed, prior to the first care visit. Accessible information was considered during this initial assessment. Risk assessments were completed and reviewed as necessary. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and

The inspection took place on 11 and 12 May 2017 and was announced.

Premier Nursing Limited provides personal care and nursing care to people in their own homes. At the time of the inspection 13 people received personal care and nobody received nursing care. People were also able to purchase other services which were not personal care such as support preparing meals or domestic help.

The service had a 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.

At the last inspection of 13 and 15 April 2016 the provider was in breach of four Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider sent us an action plan of how these regulations were to be met. At this inspection we found improvements had been made and each of the requirements had been met.

At the previous inspection of 13 and 15 April 2016 we found the provider had not ensured adequate checks were made regarding the suitability of newly appointed staff. At this inspection we found the provider had taken action to address this and the regulation was now met.

At the previous inspection of 13 and 15 April 2016 we found the provider had not ensured safe care and treatment was always provided to people by fully assessing risks and taking steps to mitigate those risks. We also found at the last inspection that medicines were not safely managed. At the last inspection we found not all staff were trained in the moving and handling of people. At this inspection we found there was a programme of moving and handling training in place and improvements had taken place. This regulation was now met.

At the previous inspection of 13 and 15 April 2016 we found the provider had not ensured staff were appropriately supported by adequate supervision, appraisal and training to enable them to perform their duties. At this inspection we found action had been taken to provide staff with training, supervision and appraisal but this was inconsistent. This regulation was now met, although we noted this is an area still in need of improvement .

At the previous inspection of 13 and 15 April 2016 we found the provider did not have an effective system to monitor, assess and improve the quality and safety of care. At this inspection we found improvements had been made in this area, but that the management of the service had not taken sufficient action to fully address all the areas we identified as in need of improvement.

People and their relatives reported they were very satisfied with the standard of care and said care staff were skilled in meeting their needs. People said they received safe care and the registered manager kept in touch with them to check if they received the care they needed. People reported the service was reliable and that they liked the consistency of staff the service provided. For example, one person told us, “I’m delighted. It’s a very good service I have nothing but praise for the agency.”

The provider had policies and procedures regarding the safeguarding of people and staff knew what to do if they considered a person was being abused. People told us they received safe care and said they felt safe with the care staff.

The CQC monitors the operation of the Mental Capacity Act (MCA) 2005. The service had policies and procedures regarding the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). People’s consent to care was sought. Staff were trained in the MCA and a good understanding of the principles of the legislation.

People said they were assisted with the preparation of food when they needed this and care records showed people’s nutritional needs were assessed.

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The inspection took place on 13 and 15 April 2016 and was announced.

Premier Nursing Limited provides personal care and nursing care to people in their own homes. At the time of the inspection 35 people received personal care and nobody received nursing care. People were also able to purchase other services which were not personal care such as support preparing meals or domestic help.

The service had a 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.

The provider had not ensured adequate recruitment checks were carried out on all staff. This included a lack of references from a previous employed and a Disclosure and Barring Service (DBS) check for one person.

Staff were not always effectively trained and supervised. Assessments and observations of staff working with people had only just started and there was a lack of checks regarding the training registered nurses had completed.

Care plans did not always give sufficient detail about how people were to be safely transferred and not all staff had received up to date moving and handling training.

There was a lack of clarity regarding the support given to one person with their medicines and records were not kept when staff administered medicines to people. The provider had not carried assessments of the competency of staff to safely administer medicines.

The provider sought the views of people regarding the quality of care they received but there was a lack of oversight of the care plans completed by staff, the medicines procedures and how staff performed. Care records were not available to us despite 48 hours notice of the inspection being given.

The CQC monitors the operation of the Mental Capacity Act (MCA) 2005. The service had policies and procedures regarding the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). People’s consent to care was sought but staff were unaware of the legislation when people did not have the mental capacity to consent to their care and treatment. This meant people’s rights regarding consent may not have been upheld.

People and their relatives reported they were very satisfied with the standard of care and said care staff were skilled in meeting their needs. People said they received safe care and the registered manager kept in touch with them to check if they received the care they needed. People reported the service was reliable and that they liked the consistency of staff the service provided.

The provider had policies and procedures regarding the safeguarding of people and staff knew what to do if they considered a person was being abused.

People said they were assisted with the preparation of food when they needed this and care records showed people’s nutritional needs were assessed.

Assistance and support with health care needs was provided when needed.

People and their relatives spoke highly of the behaviour and caring nature of staff. For example, people said they had built close working relationships with staff who listened and acted on what they said.

People reported their care was flexible to meet their changing needs and said the provider was prompt in amending any care if requested. People said how they benefitted from the social contact provided by staff.

People were aware of the provider’s complaints procedure and records showed complaints were looked into and responded to.

People’s views were sought regarding the quality of care provided. People said the registered manager was approachable and kept in touch with them to check if the service was meeting their needs.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You

At the time of this inspection the agency was providing personal care for 30 people. We spoke with two people using the service and three relatives. We spoke with the registered manager, the office manager, one registered nurse and three care workers.

Everyone that we spoke with expressed satisfaction with the care they received and the care workers who visited them. For example, one person said "They are very good and are always on time". A relative confirmed that they were given a schedule of who was going to visit and only on rare occasions was this altered. We were told that any change would be communicated to them beforehand. We were also told "There is great continuity".

We saw that care needs were assessed and that people's needs were met. We were told that the agency was very good at communicating changing need with people or with relatives. Staff spoken with confirmed that care was recorded promptly in care plans and that they could communicate by phone call or text to the agency with any concern. A relative told us " I couldn't speak more highly of the care".

People were protected from abuse and they told us they felt safe with their care workers. One person told us "They put me at ease" and "I feel very safe with them".

Staff were trained and supported to fulfill their role. Staff spoken with confirmed the the agency was a very supportive place to work. One staff member told us "It is the best ever".

Quality assurance systems were in place to monitor service provision to ensure people's needs were appropriately met.

We spoke with six people who received a service from the agency. We also spoke with the relative's of two people. Everyone that we spoke with was very complimentary about the agency and the service they received. They told us that they had regular care workers who visited them, that their privacy and dignity was promoted and that they were happy with the service they received. As one person explained, "I feel I'm very blessed. I receive a wonderful service. I have wonderful girls who come everyday. They are never late and are extremely kind, very gentle and thoughtful". Another person told us, "I have a good team of workers who come five days a week. I never have issues, they keep me informed if my regular workers can't come because they are sick or on holiday. We don't have meetings but the manager is constantly on the phone checking everything is alright".

We also spoke with four care workers. Everyone that we spoke to was very happy with the manager of the agency.

Despite everyone expressing satisfaction with the agency we found that incomplete care records, lack of formal supervision and training of staff and no formal quality assurance system had the potential to impact on the service people received.