This inspection took place on 19 and 20 November 2018 and was announced. This inspection was the first comprehensive inspection of the service since it was registered with the Care Quality Commission (CQC) on 24 November 2017.

Primavera Domiciliary Care Services Limited 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 people with a range of physical and sensory disabilities as well as people living with dementia.

Not everyone using Primavera Domiciliary Care Services Limited 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 the inspection the service was providing care and support to 22 people.

There was a registered manager in post at the time of this inspection. 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.

Although care plans identified people’s risks associated with their health and social care needs, the service did not always carry out risk assessments so that care staff were provided with direction and guidance on how to minimise the identified risk to keep people safe and free from harm.

Medicine management and administration processes were not always safely adhered to. Gaps in recording, incomplete information about medicines and lack of instruction and authorisation on how to administer medicines safely, meant that people may not always have been receiving their medicines safely and as prescribed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. However, the service did not always complete mental capacity assessments to establish people’s capacity and where people lacked capacity, decisions made in people’s best interest were not clearly documented.

Care plans were not person centred and did not detail people, likes, dislikes, preferences, cultural and religious requirements and background history to enable care staff to provide care and support that was responsive to their needs.

Care plans were not always current and reflective of people’s needs. Care plans had not been reviewed since the package of care had commenced. Where people’s needs had changed care plans had not been updated to reflect this.

Management oversight processes did not identify the issues and concerns that we found especially around medicine administration and recording. In the absence of checks and audits of care plans, the service had no insight or awareness of the issues that we found.

People and their relatives confirmed that they felt safe with the care staff that supported them. The registered manager and care staff demonstrated a good understanding of safeguarding and were able to describe the steps they would take to protect people from abuse.

The service carried out a variety of checks to ensure that only those staff identified as safe to work with vulnerable adults were recruited. There was enough staff available to meet people's care and support needs.

Assessments of people's care and support needs were carried out before they started using the service to confirm that the service could meet their needs effectively.

Care staff received appropriate and relevant training to enable them to deliver their role effectively.

People were also supported with their nutritional and hydration requirements where this had been identified as an assessed need.

People had consented to their care and support and where people were unable to consent, r