This inspection took place 25, 30 July 2018 and 1 August 2018. It was an announced visit to the service.

We previously inspected the service on the 1 and 2 December 2016. The service was rated Requires Improvement at the time. That was the second time the service had been rated Requires Improvement. We made five recommendations across the domains of Safe, Effective and Well-Led. At this inspection we found improvements had been made in all areas identified.

This service provides care and support to people living in specialist ‘extra care’ housing. Extra care housing is purpose-built or adapted single household accommodation in a shared site or building. The accommodation is bought or rented, and is the occupant’s own home. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for extra care housing; this inspection looked at people’s personal care and support service. At the time of the inspection 25 people were being supported with personal care.

The service had a registered manager in post. 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 received positive feedback from people, their relatives and staff on how the service was led. Comments included “The care assistants are of the highest quality. I cannot fault them, I am given excellent care,” “I cannot speak highly enough of them [Care workers], professional, wonderful and friendly and “They [care workers] are absolutely wonderful, incredibly kind, compassionate and caring.”

Staff were aware of how to safeguard people from abuse and knew what action to take if a concern was raised.

The provider had processes in place to ensure the staff had the required skills and experience to work with people. All the required pre-employment checks were routinely carried out.

Staff were supported to develop their skills and knowledge through training. Staff felt supported in their role and received regular communication and one to one meetings with their line manager.

Staff were aware of the need to report any incidents and accidents.

People were supported by staff that had developed a good working relationship with them. Staff were aware of people’s likes and dislikes.

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. Staff

Systems were in place to monitor the quality of the service. The provider shared learning and knowledge across the organisation to ensure people received safe, compassionate and kind service.

At the time of the inspection, there was no 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. However, the registered manager had resigned, not cancelled their registration with us and a new service manager had commenced. We pointed this out at the inspection and the provider took action immediately after to ensure they complied with the conditions of their registration. In October 2016, the service manager had applied to become the registered manager and the application was in progress with our registration team.

At the time of the inspection, 24 people used the service and there were 10 staff. People received calls in their homes at set times throughout the day. At the time of the inspection, the service did not operate 24 hours a day. However people, relatives or healthcare professionals could contact the village concierge anytime to receive support. The service had plans in place to change the service to be operating all hours of the day and night.

People were protected against abuse or neglect. We heard various comments such as, “Quite safe, I would speak to the manager if I did not feel safe with staff” and “Absolutely, I can stand up for myself and will report it to the manager. I have not any experience of that (abuse),”

There were sufficient staff to meet people’s needs and the service appropriately determined correct staff deployment. Feedback from people and relatives indicated that staff were rarely late to calls but people told us they were not concerned. When we checked care records, delays in calls were minimal or did not exist. We have made a recommendation that the service seek current guidance on implementing methods for monitoring late or missed calls.

Recruitment and selection of new staff members was not always robust and therefore did not ensure safety for people who used the service. Some documents and checks required by the applicable regulation were unable to be evidenced at the inspection. We have made a recommendation that the service follow best practice in relation to recruitment in the sector.

People’s medicines were administered, stored and disposed of appropriately. However staff did not have completed competency assessments to document their safe ability to manage people’s medicines. The service also needed to ensure that they followed the provider’s medicines procedures, and used the appropriate documents. We have made a recommendation that the service ensures it’s local medicine policy is updated and followed to reflect best practise and be fit for purpose.

We found staff received improved induction, training and supervision. The service utilised Skills for Care’s ‘Care Certificate’ for new care workers and there was evidence that this was completed. More effort was required with the commencement and completion of staff performance appraisals. We made a recommendation that the service implements a better method of collating information about staff development.

We found consent was gained before care was commenced and people’s right to refuse care was respected by care workers. The homecare coordinator checked that people’s lasting power of attorney details documented and a copy was on file.

People were positive about the caring nature of staff. Comments included, “Apart from looking after the way they (Staff) should, they (Staff) show concern and interest in me. We have a laugh and a chat. Carers are just nice” and “Carers are like a family and individually caring.” People received care and support from staff who had got to know them well and told us their privacy and dignity was respected. We found people were supported to exercise choice and where possible encouraged to be indepen

People we spoke with said that staff would regularly discuss their support plans with them and sought their agreement for any changes. One person said, "The staff discussed my support plan with me and my family in detail and then I signed to give my consent." Another person told us "Staff always discuss any changes to my support plan with me and they always take my permission before assisting me with personal care."

People's care plans contained a good level of information that ensured their needs were being met. We spoke with four people and they told us they were happy with the care, treatment and support they received. People described the care as "Very good", " absolutely brilliant" and "Just fantastic... I could not fault the staff." We also spoke to relatives of the people who used the service and one relative told us "They know (X) very well and understands his needs and requirements."

People supported by the agency and their relatives told us they felt very safe with the staff from the agency and they hadn't had to raise any concerns. Records were kept of complaints received at the service and how they had been responded to. People we spoke with did not have any complaints about their care.

On the 31 May 2012 when we had conversations with three of the people who currently receive a personal care service they told us that they felt they were able to influence their care and the way it was provided.One person gave the example of the way that care workers always provided care earlier on Sunday mornings to ensure that they were ready to go to church.

Each of the people we spoke with said that they missed the schedule of care that had previously been provided to inform them of which carers would be providing their care for each scheduled visit during the coming week. They now had to rely on care workers telling them and this did not always happen.

They told us that their care workers were always polite and treated them with respect and that they were able to discuss their care at any time either with their care workers or with the manager or team leader.

Each of the people we talked with in their own homes confirmed that they had regular visits from the manager or team leader when they could raise any concerns or discuss the way their care needs were being met. They also told us that they were regularly given opportunities to feed-back formally through service satisfaction surveys.

They told us that they felt safe and well cared for. "I couldn't wish for any better care" was how one person put it. They also told us that they were very satisfied with the standard of care they received. "The girls are all very good" was what one person told us, whilst another noted that they "got on with all the girls".

At least two of the people we spoke with had received a care service for over five years and commented on the responsiveness of care workers to short or long term variations in their care needs, which they said had always been accommodated and taken into account.

Although one person told us that some of the care workers "couldn't wash a cup up properly", they also said they had; "no gripe with them" and no one that we had conversations with called the essential competence of care workers into question.

People who currently receive a personal care service told us that they quite often talked to their carers,the service manager and team leader about various aspects of their care. They indicated that they were listened to and that in the past any minor concerns they may have had were dealt with and that they were satisfied that adjustments to their care were made appropriately as a result.

All of the people we spoke with confirmed that they received regular surveys asking them to express their views, one person suggested that these were rather too frequent.

They all confirmed that the team leader or manager carried out periodic visits at the same time as their care workers and they understood this was part of the way that their carers were supported and supervised.

Anchor Integrated Care and Housing Village -Denham Garden Village provides domiciliary care to people who require support and assistance in their homes. The service provides care and support exclusively to people who live at Denham Garden Village.

Denham Garden Village consists of over 300 properties and has a local shop, bar, Doctors surgery, swimming pool, gym and regular access to the outside community through activity clubs and good bus links.

Denham Garden Village has 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.

We found some aspects of the service were not always safe. Risk assessments had been undertaken for specific areas where potential risks had been identified to people, however these were not always in place. One person was being assisted to use a controlled medicine which was not risk assessed or given by staff who were appropriately trained to do so in line with the provider’s policy. Staff and management were able to explain how they would alleviate risks, but did not have sufficient records in place. Staff were knowledgeable on how to protect people from abuse, and were able to explain people’s needs and how they supported them. Medicines were not always managed in a safe and monitored way.

Although staff told us they felt supported, appropriate supervision was not in place. For example, staff were not receiving supervision in line with the provider’s policy. People told us they felt staff were well trained, however no system was currently in place to identify sufficiently when staff needed refresher training or extra training to help them undertake their roles. No records of competency checks were in place to ensure new and existing staff were deemed competent to undertake their roles.

People told us they felt supported by staff who were kind, caring, and knew their needs well. They told us staff always asked if there was anything extra they could do, and they always knew who was coming and at what time. The service had the added bonus of having an office on site which meant it was accessible to those who needed it. Activities were provided throughout the village and people were supported by staff to access the facilities if they wished.

Systems were not always in place to identify shortfalls in the service, however we were advised the service was in a period of transition. We were provided with a copy of the service’s action plan which demonstrated which actions were to be undertaken to ensure the service was safe, effective, caring, responsive and well led. At the time of the inspection, the service was waiting for new systems to be implemented including a training tracker and new care plans. When concerns were raised on our first day about lack of recording and evidence, we saw this had begun to improve on our second day.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We have also made a recommendation on the monitoring of complaints. You can see what action we told the provider to take at the back of the full version of this report.