We undertook an announced inspection of Abbeyfield London Polish Society on 20 April 2017.

Abbeyfield London Polish Society offers a supported living service and personal care for up to eight people. At the time of our inspection there were seven people living at the service who were all receiving the regulated activity of personal care. Each person living there had access to the communal facilities such as a lounge, dining room and a garden.

At the last inspection on 13 and 14 June 2016, we found the provider was not meeting the regulations relating to safe management of medication and good governance.

Following the inspection the provider sent us an action plan detailing how they would make improvements. At this inspection, we found that improvements had been made and that the provider had been working consistently towards meeting legal requirements fully.

There was a registered manager in post who had been managing the service for the past 28 years. 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 had made improvements in relation to medicines administration and medicines were administered, stored and disposed of in a safe way. Staff had followed the medicines administration process, which was regularly monitored and audited by the registered manager.

The service had procedures in place for the safeguarding of vulnerable people and these were being followed. All staff working at the service received safeguarding of vulnerable adults training.

People had risks to their health, safety and welfare assessed and recorded in their care plans. Staff knew the identified risks, therefore, they were able to support people in a safe way.

There was a process in place for the reporting of incidents and accidents and there was a clear audit trail of all accidents and incidents that took place at the service.

There were enough staff on each shift to be able to care for people and respond to their changing needs effectively and without delay.

The service had robust recruitment procedures in place to ensure only suitable staff were employed at the service.

All staff working at the service had the experience and the knowledge of working with people who use the service. Additionally, to ensure that people had been cared for effectively, staff received regular external training and ongoing formal supervision and appraisal, and day-to-day support from the registered manager.

The service was working within the principles of the Mental Capacity Act 2005 (MCA). People's capacity had been assessed by the service. People had consented to their care and support where they were able to do so. Staff received MCA and Deprivation of Liberty (DoL) training and had good understanding of its principles.

People were supported to maintain a sufficient and nutritious diet and meals were provided in line with people’s nutritional requirements as well as their individual dietary preferences.

People were supported to maintain good health and had access to healthcare services. The service had made suitable and prompt referrals to external health professionals to ensure people received appropriate medical assistance and they remained in good health.

People and all the family members we spoke with were very complementary about staff and they were happy with the care and support offered by the service. The interactions between people and staff were exceptionally kind, caring and compassionate and the atmosphere at the service was relaxed and homely.

Staff visited people who used the service in hospital to ensure the continuity of care and ongoing emotional support.

Staff was happy to go an extra mile to ensure people lived happy and comfortable life

The inspection took place on 13 and 14 June 2016 and was unannounced.

The service was last inspected on 22 January 2016 when we found seven breaches of the Health and Social Care Act 2008 and associated regulations. Following the inspection the provider sent us an action plan detailing how they would make improvements. At this comprehensive inspection we found the provider had taken action to address the breaches we had identified and improvements were made.

Abbeyfield London Polish Society offers personal care support for up to eight people. At the time of our inspection, eight people were living at the service, of whom six were receiving personal care. The house consisted of eight bedrooms and each person living there had access to the communal facilities such as the lounge, dining room and garden. All the people and staff living at the service were Polish. We found issues with the current registration of this service as, in effect, the service is provided and managed as a care home but is not currently registered as such. We will take up this issue with colleagues in Registration following the publication of this report.

There was a registered manager in post who had been managing the service for the past 27 years. 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 taken action to meet the concerns identified at the inspection of 22 January 2016 and had put systems in place for the recording of received medicines. However, staff did not always follow the procedure for the recording and safe administration of medicines. This meant that people were at risk of not receiving their medicines safely.

The provider did not undertake medicines audits therefore they failed to identify medicines errors.

Improvements had been made in relation to the management of risk. The risks to people’s safety were identified and managed appropriately. The provider had processes in place for the recording and investigation of incidents and accidents.

The provider had put systems in place to ensure people received their support safely. We saw a variety of health and safety checks conducted on a regular basis by staff and external agencies.

Improvements had been made to fire safety, and we saw that the provider carried out regular fire checks and fire drills. All people using the service had personal emergency evacuation plans (PEEPs) in place.

Improvements had been made to the training of staff, and we saw that all staff were receiving training in the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty.

The provider was aware of their responsibilities and had acted in accordance with the MCA and the DoL. People’s capacity had been assessed by the service. People had consented to their care where they were able to do so and nobody was being deprived of their liberty.

Recruitment procedures were in place to ensure that only suitable staff were appointed to work with people who used the service.

There were enough staff on duty to keep people safe and meet their needs, and there were contingency plans in place in the event of staff absence.

There were appropriate procedures in place for the safeguarding of vulnerable people and these were being followed.

Staff treated people with kindness and dignity and took into account their human rights and diverse needs.

People’s nutritional and healthcare needs had been assessed and were being met.

A range of activities were organised and a therapist visited twice a week and was developing an activity program with each person who used the service and engaging people in exercises.

Assessments were carried out before support began to ensure the service could provide appropriate care. C

This inspection took place on 22 January 2016 and was announced. This was the first inspection of the service since 29 May 2013 when it was registered with the Care Quality Commission (CQC).

Abbeyfield London Polish Society offers housing and personal care for up to 8 people. At the time of our inspection there were 8 people living at the service of which 5 were receiving personal care. The home consisted of 8 bedrooms and each person living there had access to the communal facilities such as a lounge, dining room and garden.

There was a registered manager in post who had been managing the service for the past 25 years.

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 did not have a full understanding of all the requirements related to the delivery of regulated activities.

Some of the staff team’s practices put people at risk of harm.

People’s medicines were not managed safely because there were not stored correctly. The administration of medicines was not recorded and there were no mechanisms in place to ensure regular stock checks of medicines were carried out.

Risks to people’s health and safety were not assessed and recorded correctly, therefore, there was no clear guidance for staff on how to minimise identified risks and how to keep people safe from injury.

There were no regular fire tests and fire drills and people did not have Personal Evacuation Emergency Plans (PEEPS) in place. Therefore, there was a risk that people using the service and the staff wouldn’t know how to act in case of a fire.

Staff did not receive MCA and DoL training and the requirements of The Mental Capacity Act 2005 (MCA) were not always followed. There were no mental capacity assessments in place therefore it was not possible to determine whether people could make decisions about specific aspects of their care.

People’s nutritional and dietary needs were assessed however they were not always reviewed and the health professionals’ guidelines were not available, therefore staff did not know how to serve food safely.

There were no robust recruitment procedures in place to ensure suitable staff were appointed to work with people who used the service.

There were not enough staff on duty and there were no contingency plans to ensure adequate cover in case of sudden staff absence.

People and their relatives were involved in the planning of their care, however, due to complex care planning systems, people’s needs were not always conveyed adequately and there was a risk of important care details and guidance being missed.

There were no robust quality assurance systems in place to ensure on-going monitoring of different aspects of the service delivery.

There were no systems in place to actively seek feedback from different stakeholders, therefore, they did not have the opportunity to evaluate the care offered by the service and influence its development.

There were some systems in place to ensure people lived in a safe environment and various periodic tests being carried out by external contractors.

Staff received safeguarding vulnerable adults training and were able to describe potential signs of abuse. They were aware of the provider’s safeguarding policies and procedures.

Staff received a variety of training that included medicines administration, safeguarding, manual handling and food hygiene. One staff member was in the process of completing their NVQ 2 in Health and Social Care.

Relatives told us the staff knew and understood the needs of their family members. They were happy with the service they received.

People told us they enjoyed the food and that an adequate choice of meals was offered to them. People’s person