Date of inspection: 21 July 2025 to 07 August 2025. Passionate About Care is a domiciliary care agency and provides personal care to people living in their own homes. CQC only inspects where people are receiving the regulated activity personal care. This is help with tasks related to personal hygiene and eating. At the time of this inspection 92 people were receiving support with personal care. We inspected to check if improvements had been made following our last inspection. The provider was previously in breach of the legal regulations in relation to safe care and treatment, complaints, staffing and good governance. Improvements were found at this inspection and the provider was no longer in breach of these regulations. People were supported to have choice and control and were involved in planning their care. Staff assessed and mitigated risks and care plans guided safe practice. Medicines were managed safely. Governance systems had improved, and the provider was keen to learn and to continue to improve the service. Staff knew people well and received appropriate training and support. There were enough staff to meet people's needs. Staff were kind and caring and had a good understanding of how to meet people’s needs. There was a system in place to enable people to express any concerns or complaints they may have.
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Passionate About Care improved from Inadequate to Requires Improvement and exited Special Measures, with continuing breaches of Regulations 12 (safe care), 17 (governance) and 18 (staffing), plus a new breach of Regulation 16 (complaints) over visit timing. Medicines, recruitment, safeguarding, training and MCA practice had improved sufficiently to no longer be in breach.
Concerns (9)
criticalCare planning: “risk assessments or care plans had not been put in place relating to people's health conditions... These included health conditions such Parkinson's disease, epilepsy and contractures.”
criticalMissed or late visits: “They [staff] turned up nearly three hours late by which time [Person's name] had wet the bed.”
criticalStaffing levels: “The failure to safely deploy staff was a continued breach of Regulation 18”
criticalComplaints handling: “The failure to effectively operate a system for identifying, receiving, recording, handling and responding to complaints was a breach of Regulation 16”
criticalGovernance: “The failure to operate effective systems to assess, monitor and improve the service and to maintain an accurate, complete record in respect of each service user was a continued breach of Regulation 17”
moderateRecord keeping: “Risk management records did not always contain enough information for staff to assess, monitor and mitigate risks effectively.”
moderatePerson-centred care: “three people told us this had not always been respected. We discussed our concerns with the registered manager who told us of their plans to ensure people were always supported by staff they felt comfortable with.”
moderateStaff competency: “Staff's knowledge about people's individual health conditions and associated risks was variable.”
minorIncident learning: “the system needed to be fully embedded as we saw two incidents on daily records that were not in the accident and incident file.”
Strengths
· Medicines were managed safely with improved guidance, PRN protocols and competency assessments
· Staff were safely recruited with appropriate DBS checks and employment history checks
· Safeguarding processes had improved; staff knew how to identify and report abuse
· Staff received induction, ongoing training and supervision; rated effective as Good
· MCA principles were followed and consent was sought before providing care
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and deploymentRequires improvement
safe: RecruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Using medicines safelyGood
safe: Learning lessons when things go wrongGood
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
caring: Supporting people to express their views and be involved in making decisions about their careRequires improvement
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesRequires improvement
responsive: Meeting people's communication needs: End of life care and supportGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement