The inspection took place on 10 September 2018 and was announced. We gave the service 48 hours’ notice of the inspection to ensure people we needed to meet with were available. The service had not been rated previously and this was the first comprehensive inspection.

The service is provided to people who live in the Burnham Court housing complex and to people living at home in the community within a five mile radius. There are 49 apartments within the complex and at the time of our inspection a care and support service was provided to 22 people on site and to seven people in the local community.

The service provides care and support to people living in a ‘supported living’ setting, so that they can live in their own home as independently as possible. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people’s personal care and support. This service is also a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community.

There was no registered manager in post at the time of the inspection, although there was an acting head of care. A new operations manager had started employment the week prior to the inspection, but was unavailable on the day. The operations manager had submitted their application to apply to be the registered manager. 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.

Although staff we spoke with said they believed there was enough staff on duty to meet people’s needs, people using the service gave mixed feedback. Some people said staff always attended planned visits. Other people said staff did not always attend visits and did not always stay for the agreed length of time because of staff shortages. The process for monitoring how long staff attended visits was not robustly monitored. Missed visits were not monitored.

Risk assessments in place did not cover all areas of risk. Risks in relation to choking had not been assessed. Other risk assessments had been carried out and where risks had been identified, care plans provided some guidance for staff on how to reduce the risks to people.

Care plans lacked detail on the level of support people needed from staff. Plans in relation to people’s clinical needs were not in place. Daily records were not always maintained. Some of the terminology used by staff in records lacked person centredness.

The providers quality assurance framework was not always robust. Provider audits were carried out. However, these did not cover all aspects of care planning and delivery. Incidents had not always been reported via the provider’s incident reporting procedure. In addition the provider had not sought feedback from people using the service.

Staff understood their responsibilities to protect people from harm and abuse. People gave mixed feedback about the staff. Although the majority of people told us that staff were “kind” and “caring”, not all did. One person said, “One member of staff is very abrupt.” Another said, “[Staff name] is not sympathetic or caring.” All the people we spoke with said staff maintained their privacy and dignity.

People and staff spoke highly of the acting manager. Medicines were in the main, managed safely.

Staff had been trained and were supported to carry out their roles. Consent to care was sought in line with legislation.

We found three breaches of the Regulations in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we told the provider to take at the back of the full version of the report.