About the service: College Road is a respite service offering accommodation and support for people with mental health support needs. Three people were supported at the time of the inspection.

People’s experience of using this service:

People told us they felt safe and satisfied with the service, and they felt that staff were supportive. People’s independence, choices and preferences were promoted. However, the provider had failed to ensure the quality and safety of the service with particular concerns as follows:

• The provider failed to take prompt and sufficient remedial action following the death of a service user in May 2018.

• Poor risk management in relation to people’s known needs, lone-working arrangements and the premises. Medicines management processes remained unsafe and staff were not supported in their roles.

• Please see more in Detailed Findings below.

Rating at last inspection: Good (January 2017)

Why we inspected: The inspection was prompted in part by information of concern shared with us by the coroner and notification of an incident involving the death of a person using the service. This incident may be subject to criminal investigation and as a result this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident, including from the coroner, indicated potential concerns about the management of risk in the service including ligature risks. This inspection examined those risks and found sufficient action had not been taken to keep people safe.

Enforcement: We identified two breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 around safe care and treatment and governance. We also identified a breach of the Care Quality Commission (Registration) Regulations 2009. Details of action we have taken can be found at the end of this report.

Following the inspection we referred our concerns to the local authority responsible for safeguarding. In addition, we requested an action plan from the provider and evidence of improvements made in the service. We took urgent enforcement action due to our concerns about the safety of the service.

The overall rating for this registered provider is ‘Inadequate’. This means that it has been placed into ‘Special Measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration, if we have not taken this enforcement action already.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or varying the terms of their registration within six months if they do not improve and similar action may have been taken already. This service will continue to be kept under review and, if needed, could be escalated to further urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded. We will have co

This inspection took place on 08 December 2016 and was unannounced. This is the first time we have inspected this service since it was registered in May 2016.

College Road is a respite service offering accommodation and support for a maximum of four adults with mental health support needs. At the time of our inspection, there were three people using the service. There was a registered manager in place. We were aware that the registered manager would not be present during our inspection as they had informed us that they would be absent from managing the home for a set period of time. We spoke with the service project lead and other managers who were present during our inspection and who had taken responsibility for managing the service in the registered manager’s absence. 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.

People told us that they felt safe using the service and we found that people’s risks were managed safely. Staff were aware of safeguarding procedures and were due to receive training in this area to help keep people safe. People were supported to take their medicines safely and as prescribed.

People were supported by sufficient numbers of staff who had been recruited safely. Staff received guidance and on-going support in their roles and demonstrated awareness of people’s needs. Where some staff training was not up-to-date, this was being addressed.

People were able to make their own decisions and this was respected by staff. People were encouraged to fulfil their own daily living tasks and access healthcare support services to promote their independence and help people to stay well.

People were supported by staff who were kind and caring and who treated people with respect. People told us they felt listened to and we found that people were involved in their care. People were at ease at the home and actions were taken to promote people’s wellbeing and recovery. Systems were effective for managing people’s needs and risks.

People spoke positively about their care and received support from staff that was responsive to their needs. Some people had been signposted towards activities of interest to them. People had been informed of how to share feedback and raise concerns with the service, the majority of feedback we sampled was positive and the service had received several written compliments.

People, staff and healthcare professionals spoke positively about the service people received and how the service was run. Staff demonstrated enthusiasm and accountability for their roles and told us they felt supported. The registered provider had systems and processes in place to support the running of the service and had identified some development areas to drive further improvement.