# Passion Domiciliary Care Ltd

Passion Domiciliary Care Ltd is a CQC-regulated home-care agency in Oldbury.

## CQC Ratings

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

Rating published: 26/08/2023

## Practical info

- Postcode: B69 1DT
- Registered manager: Mclaren, Sophie
- Local authority: Sandwell
- Region: West Midlands
- City: Oldbury
- Last CQC check: 26/Aug/2023 - 00:00

## Inspection findings

### Other

- Finding
  - Evidence: Risk assessments were developed with people's involvement to promote independence and safety.
  - Published: 2023-10-04
- Finding
  - Evidence: People reported never experiencing a missed call and always having enough staff to care for them.
  - Published: 2023-10-04
- Finding
  - Evidence: The provider worked closely with other healthcare professionals and external agencies to ensure continuity of care.
  - Published: 2023-10-04
- Finding
  - Evidence: The registered manager demonstrated duty of candour and was open and transparent about issues.
  - Published: 2023-10-04
- Finding
  - Evidence: Recruitment procedures had been improved since the previous inspection, with all safety checks now carried out.
  - Published: 2023-10-04
- Finding
  - Evidence: Staff had training on how to recognise and report abuse and they knew how to apply it.
  - Published: 2023-10-04
- Finding
  - Evidence: Staff knew and understood people well and were responsive, supporting their aspirations to live a quality life of their choosing.
  - Published: 2023-10-04
- **cultural_competency** _(moderate)_
  - Evidence: The provider's governance did not identify the relevance of equality and diversity during the assessment and care planning.
  - Published: 2023-10-04
- **care_planning** _(moderate)_
  - Evidence: 1 care record misrepresented a person's ethnicity. A certain part in relation to the person's personal care needs was missing in their care plan.
  - Published: 2023-10-04
- **staff_training** _(moderate)_
  - Evidence: Staff had not received relevant training to ensure they had the skills to support people with diabetes. There was no emphasis focused on equality and diversity.
  - Published: 2023-10-04
- **medication_management** _(critical)_
  - Evidence: Medicine competency assessments were carried out by the registered manager who had not received any training to deem them competent to do so.
  - Published: 2023-10-04
- **governance** _(critical)_
  - Evidence: Governance did not highlight the need for the registered manager to undertake relevant training, to deem them competent to undertake medicines competency assessments.
  - Published: 2023-10-04

### safe

- Finding
  - Learning lessons when things go wrong
  - Published: 2023-10-04
- Finding
  - Assessing risk, safety monitoring and management
  - Published: 2023-10-04
- Finding
  - Systems and processes to safeguard people from the risk of abuse
  - Published: 2023-10-04
- Finding
  - Using medicines safely
  - Published: 2023-10-04
- Finding
  - Staffing and recruitment
  - Published: 2023-10-04
- Finding
  - Preventing and controlling infection
  - Published: 2023-10-04

### well_led

- Finding
  - Working in partnership with others
  - Published: 2023-10-04
- Finding
  - Continuous learning and improving care
  - Published: 2023-10-04
- Finding
  - Engaging and involving people using the service, the public and staff
  - Published: 2023-10-04
- Finding
  - How the provider understands and acts on the duty of candour
  - Published: 2023-10-04
- Finding
  - Promoting a positive culture that is person-centred, open, inclusive and empowering
  - Published: 2023-10-04
- Finding
  - Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements
  - Published: 2023-10-04

## 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/1-7232031040

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