# Passion Recruitment Agency

*Operated by Passion Recruitment Agency Limited.*

Passion Recruitment Agency is a CQC-regulated home-care agency in Chertsey.

## CQC Ratings

| Key question | Rating |
| --- | --- |
| Overall | Requires improvement |
| Safe | Requires improvement |
| Effective | Good |
| Caring | Good |
| Responsive | Good |
| Well-led | Requires improvement |

Rating published: 01/06/2023

## Practical info

- Postcode: KT16 9BE
- Registered manager: Rani, Sonia
- Local authority: Surrey
- Region: South East
- City: Chertsey
- Last CQC check: 01/Jun/2023 - 00:00

## Inspection findings

### effective

- Finding
  - Ensuring consent to care and treatment in line with law and guidance
  - Published: 2023-06-01
- Finding
  - Staff working with other agencies to provide consistent, effective, timely care
  - Published: 2023-06-01
- Finding
  - Supporting people to eat and drink enough to maintain a balanced diet
  - Published: 2023-06-01
- Finding
  - Assessing people's needs and choices; delivering care in line with standards, guidance and the law
  - Published: 2023-06-01
- Finding
  - Staff support: induction, training, skills and experience
  - Published: 2023-06-01

### Other

- Finding
  - Evidence: Staff felt well supported by the registered manager and senior staff.
  - Published: 2023-06-01
- Finding
  - Evidence: Registered manager had good understanding of duty of candour and regulatory responsibilities.
  - Published: 2023-06-01
- Finding
  - Evidence: Staff demonstrated good understanding of Mental Capacity Act principles and consent.
  - Published: 2023-06-01
- Finding
  - Evidence: Care was person-centred with care plans including social history, communication support needs and individual preferences.
  - Published: 2023-06-01
- Finding
  - Evidence: Staff completed appropriate training including first aid, moving and handling, diabetes, health and safety and end of life care.
  - Published: 2023-06-01
- Finding
  - Evidence: Provider made improvements to recruitment processes including DBS checks, verified references and right-to-work checks.
  - Published: 2023-06-01
- Finding
  - Evidence: Relatives felt their family members were safe when receiving care at home and staff turned up on time.
  - Published: 2023-06-01
- **record_keeping** _(moderate)_
  - Evidence: a staff member had completed the MAR indicating they had administered the medicines at a specific time. A different staff member had completed the records of care stating they had given these medicines.
  - Published: 2023-06-01
- **incident_learning** _(moderate)_
  - Evidence: incident and accident record identified this person should not be left on their own...but this was not achievable as the staff member was not able to supervise the person all the time. There were no other actions identified.
  - Published: 2023-06-01
- **governance** _(critical)_
  - Evidence: audits of both these documents had not identified the discrepancy between the information...checks carried out were not robust enough to indicate where actions were required.
  - Published: 2023-06-01
- **medication_management** _(critical)_
  - Evidence: staff member had administered an over-the-counter medicines which had not been prescribed and was not identified in the care plan. The possible interactions this medicine could have with the prescribed medicines had not been identified.
  - Published: 2023-06-01
- **care_planning** _(critical)_
  - Evidence: when a fall had occurred, people's care plans and risk assessments were not always updated to reflect the circumstances of the fall and any impact on how care was provided.
  - Published: 2023-06-01

### safe

- Finding
  - Preventing and controlling infection
  - Published: 2023-06-01
- Finding
  - Systems and processes to safeguard people from the risk of abuse
  - Published: 2023-06-01
- Finding
  - Staffing and recruitment
  - Published: 2023-06-01
- Finding
  - Using medicines safely
  - Published: 2023-06-01
- Finding
  - Learning lessons when things go wrong
  - Published: 2023-06-01
- Finding
  - Assessing risk, safety monitoring and management
  - Published: 2023-06-01

### well_led

- Finding
  - Engaging and involving people using the service, promoting a positive person-centred culture
  - Published: 2023-06-01
- Finding
  - Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements
  - Published: 2023-06-01
- Finding
  - Continuous learning and improving care
  - Published: 2023-06-01
- Finding
  - Engaging and involving people using the service, the public and staff
  - Published: 2022-06-08
- Finding
  - Managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirements
  - Published: 2022-06-08
- Finding
  - Promoting a positive culture that is person-centred, open, inclusive and empowering
  - Published: 2022-06-08
- Finding
  - Continuous learning and improving care
  - Published: 2022-06-08

## Source

Data published by the [Care Quality Commission](https://www.cqc.org.uk/) under the Open Government Licence v3.0. Canonical page: https://homecarecompass.co.uk/agency/1-5613933002

HomeCare Compass is an independent guide and is not affiliated with the CQC.