This announced inspection took place on 9 and 10 August 2018 and was announced. It was the first rated inspection since the location was registered with CQC on 30 April 2015.

Ablewell Care is a domiciliary care service providing personal care to people living in their own houses who misuse drugs or alcohol, who had dementia, learning difficulties or autism spectrum disorders. At the time of our inspection they were providing a service for 91 people and they had 42 care staff.

A condition of registration with CQC is for there to be a registered manager in post. There was no registered manager in post at the time of this inspection. The Nominated Individual was mentoring a manager to develop into becoming registered manager in due course.

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.

We found although there were quality assurance systems in place at the time of our inspection, further improvements were required to ensure the governance was robust. For instance, not all statutory notifications had been reported to us. The submission of a statutory notification is a legal requirement when specific incidents or events had taken place in the service.

We also found safeguarding concerns were not being tracked with an outcome or analysis for trends or themes.

There was a complaints process and procedure in place however, further improvements were needed to ensure it was clearer for people what constituted a complaint. The provider had identified this from their customer feedback survey.

A recruitment audit had been completed by the provider and seven staff recruitment files only had one reference from a previous employer. The provider had therefore, identified this and were taking action to improve this.

The governance arrangements were clear with numerous quality checks in place such as monthly auditing of daily records and medication administration sheets {MARS}, recruitment practices, analysis of incidents, customer feedback and complaints.

Safeguarding concerns were being logged and reported to the Safeguarding Authority appropriately. Staff were aware of their responsibilities and were raising concern when they suspected abuse. The provider had a whistleblowing policy in place for staff to follow.

There were enough staff to deliver care for people when they needed it. People told us if the carer was running late they would phone them to inform them. Any missed visits were investigated and the root cause identified.

Medicines were being managed safely with medication administration sheets being completed. Medication errors were being recorded and analysed.

Staff were caring and were encouraging people to have as much independence as possible. People we spoke with told us they were treated with respect and dignity.

People were being asked for their consent and the service was working within the Mental Capacity Act 2005 framework.

People were receiving person centred care and were being involved in their plan of care. Likes, dislikes and preferences were being recorded.

People’s care needs were being assessed and the service were in the process of implementing the Herbert protocol which is good practice in identifying who may be at risk of becoming a missing person.

Healthcare professionals were being involved in people’s care and staff communicated with them when needed.

The provider had implemented policies in relation to Equality and Diversity and were promoting people’s rights.

The service was seeking people’s views in the form of surveys and monthly reviews. A newsletter was sent out to people to inform them of anything new or changes in the service.

The provider was seeking to encourage people to work within t