We undertook this unannounced site inspection of Total Care Nursing Limited on 20 and 27 March 2018. This inspection was prompted by information shared with CQC about the potential concerns around the management of people's care needs. We examined those risks.

Although this is the first comprehensive inspection of this location the service was previously registered at a different location where it was rated as good overall with the domain effective rated as requires improvement.

Total Care Nursing Limited is registered with the Care Quality Commission to provide personal care to people in their own homes. This service is a domiciliary care agency. It provides a service to older adults. Not everyone using Total Care Nursing Limited receives 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 our inspection, 15 people were supported with their personal care needs by the service. 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 registered manager was also the registered provider of the service. In the report, we use the term 'provider' for ease but staff and people used the term 'manager' in their conversations with us.

There were no systems in place to assess and monitor the quality of the service so this information could not be used to drive improvements. We could not be assured that all guidance staff needed to keep people safe was available and this demonstrated a lack of leadership within the service.

The provider did not ensure medicines were managed safely, Medicines Administration Records (MARs) were not appropriately completed and contained gaps. Records were not available to confirm staff's competency in this area.

People told us staff had the knowledge and skills to provide care however, staff training records did not show that all staff had completed the required training. Records relating to staff recruitment and supervision were not complete. There were no records to show that annual appraisals had been completed with staff.

We found risk assessments were insufficient and did not inform staff of people's individual support needs. Risks people faced were not always identified. This resulted in a lack of guidance for staff being available to ensure they supported people in a safe way.

People received person centred care however, care records did not always contain up to date and accurate information about people's current care needs.

Staff demonstrated an understanding of the MCA and how they applied its principles in their work. Records relating to the assessment of people's mental capacity were not completed thoroughly. The documents in use at the service required review. The provider took action to address this issue whilst we were on site.

Complaints were documented but records were not available to show they had been investigated as per the provider's complaints policy.

The provider did not have a policy in place regarding the Accessible Information Standard. We have made a recommendation about this.

The provider did not hold staff meetings to give care staff the opportunity to share their views and opinions on the running of the service. We have made a recommendation about this.

Staff told us they knew how to keep people safe and were knowledgeable about safeguarding procedures. People told us they felt safe with staff and had developed positive relationships with them.

We received positive feedback from people and relatives regarding the overall running of the service. C