The inspection took place on 18 and 20 April 2018 and was announced. The service is registered to provide personal care and supports people mostly with a learning disability and is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community [and specialist housing]. On the days of our visit there were 28 people supported by the service.

The inspection was announced as this service is small, we wanted to make sure that someone would be available when we visited.

Following the last inspection of May 2017, we asked the service to complete an action plan to show what they would do and by when to improve upon the management of agency staff and quality assurance.

At this inspection, we found that the service had increased the staffing levels so that there were sufficient staff to support people. Agency staff were required to cover unexpected staff absences on rare occasions. The agency staff had received training and senior staff support in order that they could support people to meet their assessed needs. The quality assurance systems had been developed and information from the audits had been used to improve the service and the support provided to people in relation to their assessed needs.

A registered manager was in place and was based at the service central office. At the time of our inspection the registered manager was not working at the service. The service had made the Care Quality Commission aware of this information and during their absence the service was being managed by the divisional director and supported by other senior staff in the organisation. The divisional director is the line manager of 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.

Senior staff visited the people using the service and the staff they managed regularly and did provide support themselves when the need arose. People looked at ease with staff and told us that the staff were knowledgeable and caring

Each person had a support plan and a risk assessment which identified actions which should be taken to minimise the identified risk. Staff were knowledgeable about the signs of abuse, and the actions that they would take should they have any concerns.

There was a robust recruitment process and staff received an induction, supervision and on-going training. Medicines were safely stored and administered as prescribed. There were regular planned audits of medicines and people’s finances to ensure the records were in agreement with the stock of medicines and peoples personal money.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice.

Support plans were in place for each person and focussed upon how the staff would support the person to meet their needs. People were aware of their care plans and had contributed to them. The information provided staff with the information they needed to support people. People’s preferences and choices had been identified in their support plan.

People choose the food and drinks they consumed. Some people were supported by staff to go shopping so that they could select the food and drinks they wished from the shops.

There was a complaints policy and procedure in place. Relatives informed us they were confident any complaint would be listened to and investigated. All people were supported by staff to pursue activities and interests of their choice.

The service staff provided a positive culture of support to the people using the service. Service governance was in place made up of surveys, audits and managem

Affinity Trust Ltd provides personal care and support to people in their own homes. People being supported would primarily have a learning disability but might also have another disability or mental health diagnosis. Some people have complex needs. Staffing is provided according to the person's individual assessed needs. At the time of this inspection, Affinity Trust - Suffolk was supporting 27 people.

The service covers supported living services at eight different locations across Suffolk.

Our previous inspection of 23 and 24 June 2015 found that the service required improvement. There was a breach in regulation that related to inadequate numbers of suitably qualified, competent, skilled and experienced persons. After the inspection, the provider wrote to us to tell us the action they were taking to meet the legal requirements. At this inspection, we found that further improvements were still required.

This inspection took place over five days and was an unannounced inspection.

The registered manager who was also the operations manager of the service was only in post on the first day of inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. A new operations manager had been recruited and was in post on the last two days of inspection and they were applying to become the registered manager of the service.

Improvements were needed to ensure that the way the service was staffed met the needs of the people being supported. This had been identified by the management team and they were in the process of addressing it. Recruitment of staff was done safely and checks were undertaken to ensure they were fit to care for the people using the service.

There were procedures and processes in place to ensure the safety of the people who used the service and staff understood their roles and responsibilities in providing safe and good quality care to the people who used the service.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People's consent was sought before they were provided with care and support and the service was up to date with the Mental Capacity Act 2015.

People told us that they had good relationships with the staff that supported them. People and their relatives, where appropriate, were involved in making decisions about their care and support.

People were encouraged to attend appointments with other health care professionals to maintain their health and well-being and the service worked closely with other agencies to meet people’s needs.

There was an open and transparent culture in the service and staff were very motivated. Staff understood their roles.

Improvements were needed in the quality assurance system to ensure effective oversight of the service and that the service continually improved.

Affinity Trust Domiciliary Care Services provides personal care and support to 21 people with a learning disability who live in their own homes and the community. We visited three people in their own homes.

Our inspection team was made up of one inspector. We spoke with three people who used the service, a senior manager and, three staff. Where two people were unable to verbally communicate with us we observed them and their carer. We were supported by the carers to ask questions of the people using the service, we were provided with copies of their communication plans prior to us speaking with them.

We looked at four people’s care records. Other records viewed included training records, health and safety checks, medication records, quality assurance audits and satisfaction questionnaires completed by the people who used the service, relatives, staff and health professionals who were involved with the people who used the service.

We used the evidence we collected during our inspection to answer five questions. This is a summary of what we found;

Is the service safe?

We saw that records contained detailed assessments of people's needs that had been carried out prior to them moving to the service. Any training needed for staff to support people safely was identified and provided prior to the commencement of the service and were updated annually or when a person’s needs changed and staff needed to gain further knowledge about their condition. This ensured that the staff had the relevant skills and knowledge to meet people’s individual needs.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

We saw that all staff had completed refresher training in the last year for Safeguarding of Vulnerable Adults, Mental Capacity Act 2005 and Deprivation of Liberties Safeguards. Staff were able to describe what abuse was and what they would do if they were to witness or suspected abuse. We saw that discussions had taken place within a staff meeting regarding the recent legal judgement that had taken place around the Deprivation of Liberty Safeguards. The discussion was to consider how the organisation was going to review the judgement and assess the potential impact on them.

Is the service effective?

One person told us that they were happy with the care they received and felt their needs had been met. We saw and staff told us they understood people’s care and support needs and that they knew the people well.

People’s health and care needs were assessed with them. We saw that care plans and other documents were in a format that met people’s individual communication needs. People were involved in writing and reviewing their plans of care and support. For example, we saw specialist dietary needs had been identified in care plans where required.

The training that staff had received equipped them to meet the needs of the people who used the service.

Is the service caring?

We saw that the staff interacted with people who used the service in a caring, and respectful manner. We saw that staff showed patience and gave encouragement when people were supported. One person commented, “The staff are nice.”

People’s preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes.

Is the service responsive?

We saw people had an opportunity to provide feedback on the service they received and to review their progress against their individual goals and aspirations. People reviewed their goals and aspirations with their key members of staff and provided feedback on the service the received.

We saw health and social care professionals and the staff were encouraged to provide feedback about the quality of the service provided.

Is the service well led?

Staff told us they were clear about their roles and responsibilities and that they received excellent support and supervision from the manager. Staff had a good understanding of the aims and objectives of the service. This helped to ensure that people received a good quality service at all times.

The service had a quality assurance system in place and records seen by us showed that regular audits had taken place in areas such as medication, reviewing care plans and risk assessments and training and supervision. Where any issues or concerns were identified then the manager had taken immediate action to address them.

We spoke with the manager and examined records describing the care and support provided to people who used the service. These gave us a detailed description of people’s needs and how they wished to be supported. They were accurate because people’s needs were kept under review which meant people were getting the right type of support.

We examined three staff files for evidence of staff recruitment, training and support. These showed us that the service had thorough recruitment processes which ensured that only suitable staff were employed. New staff were supported through a robust induction programme and mandatory training which ensured they could carry out their care duties effectively.

We looked at systems in place to make sure people received their medication safety. We noted that errors had occurred but the provider had taken steps to address this and to ensure that staff had the required level of knowledge to undertake this task safety.

We looked at quality assurance systems which helped to determine what the service was doing well and where they needed to improve. This was sufficiently robust and meant the provider had systems in place to evaluate their service and ensure they were delivering a service that met people’s needs.

We visited three people using the service and the staff that supported them. People told us they were encouraged to take as much control over their lives as possible and staff ensured they had all the resources and help they needed to do so, which meant they had rich, fulfilling lives.

Affinity Trust Ltd is a national organisation which provides support to people in their own homes. People being supported would primarily have a learning disability but might also have another disability or mental health diagnosis. Staffing is provided according to the person's individual assessed needs. At the time of this inspection Affinity Trust - Suffolk was supporting 27 people.

The service did not have a registered manager in place. 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 last registered manager left their employment with the service in September 2014. The service employed an operations manager who informed us that they managed the service, and had begun the process of applying to be registered.

The Commission had been made aware of an incident that had occurred at the service which was being investigated by the police. We will continue to liaise with the provider and police on this matter until an outcome is reached. Part of this inspection considered matters arising from that incident to see if people using the service were receiving safe and effective care.

Staff were trained and understood the service’s policy and procedures for responding to concerns about abuse. The staff we spoke with were able to talk about how they would recognise when people were distressed and knew what action to take to report concerns.

Some plans guiding staff how to respond in situations that included risks to people were not detailed enough, were vague and open to misinterpretation. This placed people at risk of receiving inappropriate care from staff who may not know them well. This was a possibility because agency staff had been relied on to cover on a regular basis, meaning people were not provided with the continuity of care they needed, or care from staff with the right level of training.

Permanent staff that had access to a programme of training which linked to the needs of the people they cared for. Refresher training was not always completed in line with the services own guidelines or expectations but the manager was taking action to address this.

Where people lacked capacity, appropriate actions had been taken to ensure decisions were made in the person’s best interests. A complaints procedure was in place. People’s concerns and complaints were listened to, addressed in a timely manner and used to improve the service.

People’s nutritional needs were being assessed and met. Where concerns were identified about a person’s food intake, or ability to swallow, appropriate referrals had been made for specialist advice and support. People were provided with a variety of meals and supported to eat and drink sufficiently.

Staff had good relationships with people who used the service. Staff respected people’s privacy and dignity at all times and interacted with people in a caring, respectful and professional manner.

Staff knew and were able to talk about the values of the service and expectations about the care they provided. They felt the leadership was open and approachable. They also felt listened to and as a result staffing and training had improved.

The service provided care and support for people who often had complex and changing needs. We were concerned that the provider had not fully considered the challenges to ensuring robust managerial oversight of the activities they were providing across a large geographic area. The absence of a registered manager for over eight months and failure to notify us about this showed poor governance and understanding about the requirements relating to the management of regulated services. The provider acknowledged this and took steps to address it during our inspection.

During this inspection we identified a breach of 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