We carried out an unannounced inspection of this service on 26 June 2018. Cloud House is a care home, specifically caring for up to ten women living with mental health conditions, learning disabilities or substance misuse problems. At the time of our inspection seven people were living in the service.

People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. This service provides personal care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

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.

At our last inspection on 30 January and 2 February 2017, the service was rated 'Requires Improvement'. We identified four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The systems for the safe management of medicines had not been maintained which meant people had not received their medicines as prescribed. Quality assurance systems and audits had not operated to assess and improve the quality and safety of the service provided. Recruitment processes had not been operated to ensure staff were of good character and the service had not maintained records as required. Staff had not received the training required to perform their roles. We also found one breach of the Care Quality Commission (Registration) Regulations 2009, as the service had not submitted notifications of incidents or allegations of abuse.

At this inspection we found the service had addressed all previous breaches and improvements had been made. The service has therefore been rated as ‘Good.’

Safeguarding procedures were in place and staff demonstrated a clear understanding of what abuse was and how to safely report any concerns. The service had detailed risk assessments in place to guide staff to best support people using the service. Infection control was being managed in a safe way and staff were provided with personal protective equipment to prevent the spread of cross infection. Staff were recruited safely to ensure they were suitable to support people and staffing levels were sufficient. People’s medicines were managed safely by staff who had received appropriate training.

The service completed pre-admission assessments to ensure they were able to meet people’s individual support needs. Staff had completed specific training, received an induction and had regular supervision to allow them to provide high quality support. There was clear evidence of the service working in a way which promoted equality and diversity and aimed to protect people from discrimination. Staff understood the Mental Capacity Act 2005 (MCA). MCA is law protecting people who are unable to make decisions for themselves. People who had capacity to consent to their care had signed their care plans and risk assessments and where consent was not applicable, the appropriate authorisation procedures had been completed. These are referred to as the Deprivation of Liberty Safeguards (DoLS). The service promoted healthy living through encouraging people to participate in activities and eat healthy food as well as access support from other health and social care professionals. People had choices around their meals. A weekly menu was prepared with people.

Records and observations confirmed the service worked in a person-centred way and detailed people’s individual preferences and support needs. People were observed to be able to approach staff at any time for support and staff were seen to be caring in their responses. Advocacy services were available to help people have their views and wishes heard. The service

The inspection took place on 30 January and 2 February 2017 and was unannounced. The service is a care home for up to ten women living with mental health conditions. At the time of our inspection six people were living in the home.

The home 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.

The service was last inspected in April 2016 when we identified two breaches of regulations, made three recommendations and rated the service Requires Improvement overall. At this inspection we found the service had addressed the previous breach of Regulation 9 of the Health and Social Care Act (Regulated Activities) Regulations 2014. The service now had clear records that people’s needs were assessed and reviewed regularly. However, the service had failed to address the breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Although records showed they had commissioned training resources to ensure staff had sufficient skills and knowledge to perform their roles, these had not been effectively implemented.

The home had followed our recommendation regarding medicines record keeping. However, systems to monitor medicines had not been maintained and errors in medicines administration were found during the inspection. Medicines had not been managed in a safe way that ensured people received them as prescribed. The provider took immediate action to address these issues.

Care files contained a range of risk assessments with clear measures in place for staff to follow in order to mitigate risks. Where people presented with behaviours which could challenge the service, there were appropriate and detailed plans in place to de-escalate situations with clear instructions regarding the use of physical intervention as a last resort. The home had a number of general risk assessments, which included measures which were restrictive on people living in the home. We have made a recommendation about restrictive risk assessments.

There were enough staff on duty to meet people’s needs. Records showed safe recruitment practice had not been followed.

Staff were knowledgeable about the different types of abuse people might be vulnerable to and knew how to escalate concerns. Incidents that should have been raised as safeguarding alerts had not been escalated appropriately. We have made a recommendation about safeguarding adults.

Care plans were personalised and contained a high level of detail about how to meet people’s individual needs and preferences. People were supported to join in a range of community and in house activities. Information about people’s care plans and activities was not always in a format that was accessible to them. We have made a recommendation about making information accessible to people living in the home.

People told us they liked the food. People were supported to be involved in meal preparation and specialist religious dietary requirements were met. Menu choices and other aspects of shared living were discussed at regular house meetings where people could make decisions about the running of the home. People were supported to access healthcare services as required and to maintain their health. Where people had health conditions which required specific guidelines these were clear and in place.

The home sought consent from people and where people lacked capacity to consent to their care appropriate applications to deprive them of their liberty had been made. Where people lacked capacity to make decisions in some areas of their lives, but could make other decisions, information in care plans was not always clear about what support they needed to make their own choices.

The inspection took place on 12 and 15 April 2016 and was unannounced. The service is a care home for up to 10 women living with mental health conditions. At the time of our inspection eight people were living in the home. The service was last inspected in August 2014 when it was found to be meeting the standards inspected.

The home 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. In addition, an interim manager was in post who was responsible for the day to day management of the service.

The home was not completing assessments of people's needs before they moved into the service. The process for ensuring that the service was able to meet people's needs was informal and not recorded.

Staff were not receiving the training they needed to perform their roles, and support provided to staff during their induction to the service was not recorded.

People's medicines were managed in a way that ensured they received them safely. However, there were no mechanisms to ensure the service knew the quantity of medicines in the building. We have made a recommendation about medicines audits.

Staff were recruited to the service safely and appropriate checks were carried out to ensure they were suitable and qualified to perform the role. However, the process by which staff were promoted to more senior roles was not clear. We have made a recommendation about internal recruitment processes.

Incidents were recorded and reviewed by the management team. However, the section regarding the management response and lessons learnt did not include analysis or updates to support. We have made a recommendation about responding to incidents.

Care plans and risk assessments lacked detail and were not personalised when we reviewed them. The service updated care plans and risk assessments during the inspection to make them more detailed and personalised. People held monthly meetings with staff where their care plans were discussed, reviewed and updated. These meeting included a discussion of any health appointments that people had attended. People were supported to follow the advice of healthcare professionals.

Staff had a good understanding of safeguarding adults, and most people told us they felt safe in the home.

The staffing levels were determined by the needs of the people living in the home. There were sufficient numbers of staff to ensure people's needs were met.

People's consent to their care and treatment was clearly recorded. Where people lacked capacity to consent to their care and treatment the service had followed legislation and guidance.

People were supported to choose their meals and were supported to cook their own food if they wished. People were supported to eat and drink enough to maintain a balanced diet. The home held weekly meetings where people chose what food would go on the menu. These meetings were also used to provide feedback on activities and other aspects of the home. People were involved in making decisions about the home. People told us, and records confirmed that they had not made any complaints about the service. People told us they knew how to make complaints.

Staff completed an induction which included a two week period where they shadowed and spent time getting to know people who lived in the home before providing care. This facilitated the development of positive, caring relationships between staff and people who used the service. Staff treated people with dignity and respect and promoted their independence.

The management team completed a range of audits and feedback surveys to monitor the quality of the service. People and staff spoke highly of the management team and described them as appr

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

This is a summary of what we found-

Is the service safe?

Risk assessments were in place which included information about how to meet people’s needs in a safe manner. Before staff commenced working at the service checks were carried out to test their suitability to work with vulnerable adults. These included references and criminal records checks. Various health and safety checks were carried out to ensure the premises were safe including testing of electrical equipment and gas safety checks. Systems were in place to reduce the risk of fire at the home.

Is the service effective?

Care plans were in place which included information about how to meet people's needs. Staff we spoke with had a good understanding of people's needs and how to support them. People told us that the service supported them to access health care services. One person said "staff go with me to the doctor and dentist and that kind of thing." Most people told us the service supported them to meet their needs.

Is the service caring?

Most people we spoke with told us they were treated well by staff. One person told us they had "very nice staff." Staff we spoke with told us how they promoted peoples dignity for example by enabling people to make choices such as about what they ate and what time they got up and went to bed. One person said "I decide when to get up." We observed staff interacting with people in a polite and respectful manner, for example knocking on bedroom doors and waiting for a reply before entering.

Is the service responsive?

People's needs were assessed before they moved into the service to determine if it was a suitable placement. We saw that care plans were subject to review to help ensure they reflected people's needs as they changed over time.

Is the service well-led?

The service had a registered manager in place and staff told us they found the manager to be approachable. The service had various quality assurance and monitoring systems in place, some of which included seeking the views of people who used the service. For example the provider carried out a monthly visit of the service which involved seeking the views of people.

We spoke to three people using the service who all spoke positively about the care they received. One person said, "it's ok here. we can go to bed any time and do what we want to. I am ok here." Another person said, "it's alright here, the staff are alright."

People who use the service told us that they felt safe at the home and were well looked after. One person we spoke with said,"the staff are not bad, they do everything for you." We found that people who use the service were protected from the risk of abuse, because the provider had policies and procedures in place and staff knew about them.

People who use the service did not comment on the administration of medication. However, we found that people were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

There was an effective complaints system available. Comments and complaints people made were responded to appropriately.

There are three people living in this home at present. During our visit we spoke to two people who lived here. They said ‘’ The food is good’’ and ‘’There are things to do during the day’’.

Staff spent time with people that live here developing individualised care plans with relevant risk assessments. Regular meetings were held in the home, involving people who live here and staff.

People were able to make choices about how they spent their days. The care plans documented how staff supported each person in completing tasks in order that their independence was promoted.

Staff had received training to deliver care and support to the people they were looking after. Staff said they were supported by the manager to deliver good care in this home. People who lived here displayed some challenging behaviour at times. Staff had received behaviour training and used de-escalation behaviour management techniques with success.

We saw good interacting between the people who lived here and staff. The atmosphere was calm and relaxed throughout our visit.