The inspection of Honeybourne Gate took place on 20 and 21 June 2018 and was announced. 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.

We only inspected the records, policies and procedures relating to those people who received support with the regulated activity of personal care.

At the last inspection of Honeybourne Gate in July 2017 we rated the service ‘Requires Improvement’ overall. We found two breaches of the regulations. This was because adequate records in relation to people employed and the monitoring of the service had not been kept. The provider had not ensured staff were fit and proper to carry out the regulated activity of personal care.

After the inspection provider sent us an action plan of the actions they would take to meet these legal requirements. At this inspection we followed up on their actions and found that improvements had been made and the service now met the legal requirements.

A registered manager was not in place as required by their conditions of registration. 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 and associated Regulations about how the service is run. However, an acting general manager had been appointed and was managing the service until the newly appointed manager came in to post.

The acting general manager followed safe recruitment practices when recruiting new staff. The provider and deputy managers had a good insight into the quality of care being delivered and monitored the service personally. The provider had sought support from an independent consultant to assist them in monitoring of the service and we saw this had resulted in improvements in how the service was monitored and managed.

People were provided with care and support according to their needs and risks. People’s risks had been identified and were being managed by staff who knew them well. People’s care plans provided staff with the information they needed to support people. Robust and safe systems were in place if people required support with their medicines.

Staff understood how they should apply the Mental Capacity Act 2005 if they were required to support people who lacked mental capacity to make decisions about their care and support. Staff worked closely with health care professionals and people’s families. Relevant health and social care professionals were involved with people’s care when their needs had changed.

People and their relatives were positive about the caring nature and told us they were supported by staff who were kind and compassionate. They were confident that any concerns would be dealt with promptly.

Staff felt trained and supported to carry out their role. The deputy managers were involved in the delivery and management of people’s personal care, which allowed them to monitor the well-being of people and management of staff. Any concerns or accidents were reported and acted on to ensure people received care which was safe and responsive to their needs. Staff were trained in safeguarding people and protecting them from harm.

The inspection took place on the 12 July 2017 and was announced. This was the services first inspection since their registration with CQC.

Honeybourne Gate is a retirement complex which provides a personal care and support service to people in their own accommodation as required. At the time of our inspection there were two people receiving personal care from the service.

Honeybourne Gate 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.

People were happy with their care and support they received from staff. They told us they felt safe amongst staff and were treated with kindness. They were supported to maintain their independence and were consulted about their care. However, people were at potential risk of receiving care from unsuitable staff because robust recruitment procedures of new staff had not been applied.

Systems were in place to check the quality of the service provided including regular meetings; however this did not include the monitoring of the provider’s recruitment processes. Some of the provider’s polices did not reflect the practices of the service. This meant people were at risk of not being supported by staff who were familiarise with the service’s protocols or current legislative guidance.

People’s care, risk and support needs had been assessed and recorded. People received a care package which was tailored to their needs and preferences. People took part in a range of activities and had opportunities to socialise with others. Where required, they were supported in planning and preparing their meals according to their wishes. People’s medicines were safely managed and administered correctly.

Staff had been trained to carry out their role and report any concerns or incidents. The registered manager was accessible to people and staff and dealt with daily concerns.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to the service’s recruitment and governance processes. You can see what action we told the provider to take at the back of the full version of this report.