When we inspected in September 2016 we found that improvements were required under the five questions we always ask about safety, effectiveness, caring, responsiveness, and well-led.

When we inspected again on 28 February and 1 March 2017, we found improvements had been made but we needed to be assured that these had been sustained and embedded into practice. We found that safeguarding investigations allocated to the provider to follow up prior to our inspection had not always been satisfactorily completed. This was a breach of regulation 13(3) of the HSCA 2008 (Regulated Activities) Regulations 2014, Safeguarding service users from abuse and improper treatment. The provider had also been in breach of Regulation 17 (1) (2) (a) of the HSCA 2008 (Regulated Activities) Regulations 2014, Good Governance. This was because we found that the systems adopted by the provider to monitor the quality of care that people received had not consistently been effective.

At this inspection in May and June 2018 we saw that all the improvements had been sustained and that the provider had taken timely and appropriate action and was no longer in breach of the above regulations.

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.

The service met all relevant fundamental standards related to staff recruitment, training and the care people received. People’s care was regularly reviewed with them so they received the timely support they needed. Staff sought people’s consent before providing any care and support. They were knowledgeable about the requirements of the Mental Capacity Act (MCA) 2005 legislation.

People were cared for by staff that knew what was expected of them and the staff carried out their duties effectively. Staff were friendly, kind and compassionate. They had insight into people’s capabilities and aspirations as well as their dependencies and need for support. They respected people's diverse individual preferences for the way they liked to receive their care.

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 systems in the service supported this practice.

People that needed support to manage their medicines received this. People were supported to eat and drink whenever this was part of their agreed plan of care.

The provider and registered manager led staff by example and enabled the staff team to deliver individualised care that consistently achieved good outcomes for all people using the service.

The service worked in partnership with other agencies to ensure quality of care across all levels. Communication was open and honest, and any improvements identified were worked upon as required. There were arrangements in place for the service to make sure that action was taken and lessons learned when things went wrong so that the quality of care across the service was improved.

People, relatives and staff were encouraged to provide feedback about the service and this was used to drive continuous improvement. The provider had quality assurance systems in place that were used to review all aspects of the service and drive improvements whenever needed.

People how to complain and were confident that if they had concerns these issues would be dealt with in a timely way.

This inspection took place over two days on 28 February and 1 March 2017. The Care Bureau is registered with the Care Quality Commission (CQC) to provide personal care to people living in their own homes. At the time of this inspection The Care Bureau was providing care and support to 67 people totalling 630 hours of care each week.

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.

The provider had not maintained adequate oversight of the care and support that people received. Shortfalls in the service that people received from the Care Bureau had not been identified by the provider in a timely manner because the quality assurance systems utilised were not effective. During this inspection the provider outlined their plans to adopt a more robust system of quality assurance however, this had not yet been embedded in practice.

Care staff continued to feel under pressure because their schedules did not make allowances for travel time. The time taken by care staff to travel between care calls had been considered by the provider when developing staff schedules however, care staff had not been communicated with effectively and did not understand that the time shown on their schedule provided a 30 minute window in which they should arrive to people to provide their commissioned care.

Care staff felt under pressure to provide people’s care quickly in order to travel to and arrive to provide other people’s care on time. This had impacted upon some people’s experience of receiving care and support and meant that staff could not engage in a consistently positive manner with people receiving care and had created a task led culture amongst some care staff.

People could not be assured that their complaints would be responded to appropriately and improvements were required to the way in which feedback from people was managed.

People’s care records contained risk assessments and risk management plans to mitigate the risks to people. These plans gave clear instructions to staff on how to minimise the identified risks. People’s needs had been assessed and detailed plans of care had been developed to guide staff in providing care in partnership with people who used the service.

People’s health and well-being was monitored by staff and they were supported to access relevant health professionals in a timely manner when they needed to. People were supported to have sufficient amounts to eat and drink to help maintain their health and well-being.

At this inspection we found the service to be in breach of two regulations of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014.

This unannounced inspection took place over three days on the 6, 7 and 9 September 2016.

The Care Bureau is registered with the Care Quality Commission (CQC) to provide personal care to people living in their own homes. At the time of the inspection The Care Bureau was providing care and support to 223 people totalling 1700 hours of care and support each week.

There was not a registered manager in post however the provider had recruited a new manager who told us that they would submit an application to CQC to become the 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.

There was a systematic failure in the leadership and governance of the service which had resulted in safe systems of care failing to be implemented consistently. People were exposed to the continuing risk of harm because the provider had not taken action to assure themselves that people were receiving safe care and support. There were insufficient resources available to coordinate people’s care and support consistently or safely.

People were not protected from harm because procedures and processes which protect people from potential abuse, by ensuring safeguarding matters are responded to appropriately had not been implemented. Staff had failed to recognise incidents which should be reported to the safeguarding team, investigate incidents or to take appropriate action to mitigate the risks to people

People had not always received their planned calls or calls were late resulting in missed and late medicines for people. People could not be assured that they would receive their medicines. Records of the medicines that people had been administered were not completed appropriately and systems had not been implemented to audit people’s medication administration records and investigate potential medicine errors.

Staff providing care and support did not have the skills and knowledge that they required to care for people safely. Staff did not apply the training that they had received on a day to day basis and training in key areas was not refreshed.

People could not be assured that they would receive adequate food and nutrition. People who required support to prepare their meals did not always receive them because staff did not turn up or they were late The provider had failed to implement systems to identify and resolve missed or late calls to people.

People could not be assured their complaints would be managed effectively or that the provider would learn from people’s feedback and implement improvements. Systems were not being operated to manage, respond to and resolve people’s complaints. We found numerous examples of people making complaints that had not been acknowledged by the provider.

People’s individual plans of care were not reflective of their current care needs. People received inconsistent levels of care and support that was not provided according to their individual preferences.

There was a lack of leadership, governance and managerial oversight of the service. There was a systematic failure to implement any of the provider’s procedures for quality monitoring. This had resulted in the shortfalls highlighted in this inspection failing to be addressed adequately by the provider and placed people at the continuing risk of harm.

At this inspection we found the service to be in breach of eight regulations of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014 and one regulation of the Care Quality Commission (Registration) Regulations 2009. The actions we have taken are detailed at the end of this report.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. Services in

As part of our inspection we reviewed care plans for some of the people who used the service. We saw that the plans were based on the people’s assessed needs and requirements. Care plans were detailed and took account of people's individual requirements.

We spoke with members of staff who told us training was, “very good” and gave them a good understanding of how to meet people's needs and what to do if there were any problems.

We also spoke to people who used the service and they told us, “I am very pleased with them.”

We looked and the Provider’s policies and procedures for Safeguarding, and for Quality Assurance. We found that the policies in place meant that services were reviewed regularly and any concerns were managed appropriately. We also found that the Provider had appropriate arrangements in place for the recruitment and support of staff.

We carried out a routine inspection of the service.

We spoke with five people who used the service. We also spoke with five relatives about their views of the care provided.

All the people we spoke with were generally very satisfied with the care supplied by the service. Staff were seen as professional, caring and helpful. There were comments from two people that staff did not always turn up on time. One person said this could be a problem at lunchtime because she felt hungry, and it took up to an hour for the care staff to come to help her. One person also said staff did not always knock before they came into her bedroom, which could be embarrassing. The manager said that these issues would be followed up.

People generally highly praised care workers: One person said: '’ I see the staff as my friends. They help me with anything I ask of them‘’. One relative said: ‘’We went over the care plan in detail at the beginning. I was impressed by how receptive they were to my views’’.

We spoke with five people who used the service. We also spoke with five relatives about their views of the care provided.

All the people we spoke with were generally very satisfied with the care supplied by the service. Staff were seen as professional, caring and helpful. There were comments from two people that staff did not always turn up on time. One person said this could be a problem at lunchtime because she felt hungry, and it took up to an hour for the care staff to come to help her. One person also said staff did not always knock before they came into her bedroom, which could be embarrassing.

People generally highly praised care workers: One person said: '’ I see the staff as my friends. They help me with anything I ask of them‘’. One relative said: ‘’We went over the care plan in detail at the beginning. I was impressed by how receptive they were to my views’’.

This inspection took place on the 28 & 29 September 2015 and was unannounced. The service is registered to provide nursing and personal care to people in their own homes when they are unable to manage their own care. At the time of the inspection there were approximately two hundred people using the service ranging from people who received one visit per week to people who received visits up to four times a day.

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

Care plans were not always updated to reflect people’s changing needs and some new staff felt that the training provided was not sufficient enough for them to carry out their role. The provider was addressing this issue by the end of our inspection.

The provider had robust recruitment systems in place which included appropriate checks on the suitability of new staff. There was a stable staff team and there were enough staff available to meet peoples’ needs.

Care records contained risk assessments to protect people from identified risks and help to keep them safe. They gave information for staff on the identified risk and informed staff on the measures to take to minimise any risks.

People were supported to take their medicines as prescribed. Records showed that medicines were obtained, stored, administered and disposed of safely. People were supported to maintain good health and had access to healthcare services when needed.

People were actively involved in decision about their care and support needs. There were formal systems in place to assess people’s capacity for decision making under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). People felt safe and there were clear lines of reporting safeguarding concerns to appropriate agencies and staff were knowledgeable about safeguarding adults.

Care plans were in place detailing how people wished to be supported and people were involved in making decisions about their care. People participated in a range of activities both in their own home and in the community and received the support they needed to help them do this. People were able to choose where they spent their time and what they did.

Staff had good relationships with the people who they cared for. Complaints were appropriately investigated and action was taken to make improvements to the service when this was found to be necessary. The manager was accessible and monitored the quality of the service provided. Staff and people were confident that issues would be addressed and that any concerns they had would be listened to.