We carried out an announced inspection at Housing and Care 21 – Belsize Court on the 2 and 7 August 2018. At our last comprehensive inspection on 21 April 2017 we found the service was breaching regulations relating to medicines management and assessing risks to people, caring for people in line with the Mental Capacity Act 2005 (MCA) and also good governance. We issued the provider with two warning notices in relation to the repeated breaches of safe care and treatment and good governance. Following that inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe, effective and well led to at least good. At our next focussed inspection in August 2017 we found the provider had met the requirements and was no longer in breach of the regulations. However, we did not improve the rating for these questions from requires improvement because to do so requires consistent good practice over time.

At this inspection we found the provider had embedded the required changes into practice and sustained the necessary improvements. We have therefore improved the overall rating to Good.

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 service.

People using the service lived in their own private flats in a large purpose-built building within the town of Sutton. Belsize Court has a total of 63 flats for people aged 55 years and older.

Not everyone using Housing and Care 21 – Belsize Court receives regulated activity; CQC only inspects the service being received by people provided with ‘personal care’; help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided. At the time of our inspection the service was providing personal care to 58 people

The service is required to have a 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. The manager had started at the service in April 2018. At the time of our inspection visit the manager had made an application to become registered.

The provider had sustained improvements to the way they managed medicines. We found medicines continued to be administered safely and people received them as prescribed.

People felt safe and well cared for. Staff knew how to recognise and report any concerns they had about people’s care and welfare and how to protect them from abuse. Risks were managed so that people were protected from avoidable harm and were not unnecessarily restricted.

Themes and trends in relation to accidents and incidents were reviewed and followed up with action where necessary.

The provider followed safe recruitment practice to check staff were of good character and suitable for their roles. Staffing was managed flexibly so that people received their care and support when they needed it.

People were supported by regular staff who were appropriately trained and supervised. Management observed how staff cared for people in their home to ensure their practice was safe and people received the support they needed.

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.

The care plans evidenced people's involve

We carried out an unannounced comprehensive inspection of this service on 12 May 2016 at which we rated the service 'Requires improvement' and found breaches of two regulations. These related to providing safe care and treatment, particularly in identifying and managing risks to people's safety and good governance in relation to systems to review service quality. We undertook an announced focused inspection on 25 October 2016 and found they were then meeting legal requirements. At our comprehensive, announced inspection on 21 April 2017 we found the service was breaching regulations relating to medicines management and assessing risks to people, caring for people in line with the Mental Capacity Act 2005 (MCA) and also good governance. We rated the service requires improvement again and issued the provider with two warning notices in relation to the repeated breaches of safe care and treatment and good governance.

This inspection took place on 26 July and 2 August 2017 and was announced. We gave the provider 48 hours’ notice to ensure a representative from the management team would be available to speak with us. At this inspection we found the provider had met the requirements of the two warning notices we issued to them. The provider was also no longer breaching the regulation relating to the MCA.

Housing & Care 21 – Belsize Court is an extra care scheme. Belsize Court has a total of 63 flats for people aged 55 years and older. Thirty people using the service at the time of the inspection were receiving support from staff with their personal care, the majority of whom were living with dementia and some had other complex mental and physical health needs. Both the housing service and the care service were provided by Housing &Care 21.

The service did not have 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. At our previous inspections we found the service also did not have a registered manager. The manager who had been in post had begun the process to register, however, they resigned a few days before we announced our inspection due to personal reasons. The provider was recruiting for a new manager who would register with us.

People’s medicines were managed safely by staff as the provider had made improvements to medicines management. They contracted a new pharmacy who supplied medicines administration records printed with prescriber’s instructions. Previously staff recorded the prescriber’s instructions by hand and we found this led to recording errors which meant people did not always receive their medicines as prescribed. This improvement meant the risks of recording errors were reduced and medicines management was now safer.

The management team had reviewed their processes to assess whether people required authorisations of deprivations of liberty by the Court of Protection as part of keeping them safe. The provider had liaised with the local authority to request they make authorisations for people where required.

Risks to people were reduced as the provider now identified and assessed risks to people appropriately, putting management plans in place to mitigate these.

The provider implemented a robust action plan to assess, monitor and improve the service in relation to the concerns we identified at our previous inspection.

We carried out an unannounced comprehensive inspection of this service on 12 May 2016 at which we rated the service 'Requires improvement' and found breaches of two regulations. These related to providing safe care and treatment, particularly in identifying and managing risks to people's safety and good governance in relation to systems to review service quality. We then undertook a focused inspection on 25 October 2016 and found they were then meeting legal requirements.

Before this inspection we received concerning information about medicines management practices. We carried out this inspection to look at these concerns as well as all other aspects of service provision. This inspection took place on 21 April 2017 and was announced.

Housing & Care 21 – Belsize Court is an extra care scheme. Belsize Court has a total of 63 flats for people aged 55 years and older. Thirty people using the service at the time of the inspection were receiving support from staff with their personal care, the majority of whom were living with advanced dementia and some had other complex mental and physical health needs. Both the housing service and the care service were provided by Housing &Care 21.

At our previous inspections the service did not have a registered manager. At this inspection the service still did not have a registered manager. The manager who was newly in post at our last inspection had not yet completed the process to register with us. 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.

Staff did not manage people’s medicines safely. Senior staff copied the prescribers’ instructions onto people’s medicines administrations records and we found errors in transcribing which meant people did not always receive their medicines as prescribed. Poor stock control by the provider meant people sometimes ran out of medicines and prompt action was not taken to obtain the required medicines.

Appropriate risk assessments and management plans were not always in place in relation to some risks to people, including risks relating to malnutrition, alcoholism, skin breakdown, behaviours that challenged and risks relating to catheter care.

Robust systems were not in place to review the quality of service provision and medicines audits failed to identify any of the issues we found during our inspection. In addition auditing systems had not identified the other issues we found during our inspection. Some information in care plans was inaccurate which meant people were at risk of receiving inappropriate care.

The management team did not appreciate their responsibilities to ensure applications were made to the Court of Protection to deprive people of their liberty lawfully as part of keeping them safe. Staff had a limited understanding of their responsibilities under the Mental Capacity Act 2005 (MCA) and what constitutes a deprivation of liberty.

People were positive about staff and told us they were kind. However we observed staff did not always respond appropriately to people living with dementia who were disorientated to time and place and agitated. In addition staff did not always ensure people’s privacy and dignity was maintained when providing personal care.

A staff training programme was in place although suitable training in relation to medicines management and catheter care in order to help staff understand people’s needs was lacking. Staff were supported through supervision and new staff followed a suitable induction. Further training was provided to staff such as diplomas in health and social care and leadership and management qualifications for the management team.

Staff were recruited through robust procedures to check their suitability. There were enough staff deployed to support people. Staff understood how to respond if they suspected peo

We carried out an unannounced comprehensive inspection of this service on 12 May 2016 at which we rated the service ‘Requires improvement’ and found breaches of two legal requirements. These related to providing safe care and treatment, particularly in regards to identifying and managing risks to people’s safety, and good governance, particularly in regards to the systems in place to review service quality. Following our inspection the provider sent an action plan and told us they would make the necessary improvements by 27 July 2016.

We undertook a focused inspection on the 25 October 2016 to check that they now met legal requirements. This report only covers our findings in relation to this inspection. You can read the report from our previous comprehensive and focussed inspections, by selecting the 'all reports' link for ‘Housing & Care 21- Belsize Court’ on our website at www.cqc.org.uk.

Housing & Care 21 – Belsize Court is an extra care scheme. Belsize Court has a total of 62 flats. 34 people using the service were receiving support from staff with their personal care. People using the service were aged 55 years and older, and had a mix of physical and learning disabilities. Both the housing service and the care service were provided by Housing and Care 21.

At our previous inspection the service did not have a registered manager. At this inspection they continued to not have a registered manager. A new manager was in post and they had begun their application to become registered. 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 staff had reviewed and updated risk assessments to ensure they identified the risks to people’s health and safety. Staff had developed plans to manage and mitigate those risks. This included in relation to moving and handling, personal care, skin integrity and prevention of falls.

The new manager provided leadership and management at the service. They were now using the provider’s systems to review key performance information and a full service audit had been undertaken to review the quality of service provision. Improvements had been made where the systems identified these were required.

The provider was now meeting the breaches of regulations identified at our previous inspection.

We undertook an announced inspection on 12 May 2016. The service was registered in June 2015 and this was their first inspection.

Housing and Care 21 – Belsize Court is an extra care scheme. Belsize Court has a total of 63 flats. Thirty-four people using the service were receiving support from staff with their personal care. People using the service were aged 55 years and older, and had a mix of physical and learning disabilities. Both the housing service and the care service were provided by Housing and Care 21.

At the time of our inspection the service did not have a registered manager in post. The provider was in the process of recruiting a new 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. The provider had recently undertaken a management restructure and in the days prior to our inspection, Belsize Court had been allocated a new operations manager. The operations manager was supporting the team leader to manage the service, whilst the recruitment of a registered manager was being undertaken.

The staff had not consistently identified, managed and mitigated the risks to people’s safety. We found that appropriate risk assessments and management plans were not in place in regards to the risk of people falling and risks associated with moving and handling and diabetes care.

Robust systems were not in place to review the quality of service provision. We found that systems were not in place to learn from previous incidents and focus on continuous service improvement. At the time of our inspection information from incidents and complaints was not reviewed to identify any trends or themes.

We found that some care records were not specific to people’s individual needs. Some contained incorrect or conflicting information which meant there were risks people might receive inappropriate care.

Staff were aware of people’s support needs. Staff liaised with people, their family and reviewed information from the local authority to identify people’s support needs, and how people wanted to be supported. People were involved in decisions about their care and were provided with a choice about how they were supported, as well as day to day decisions. Staff respected and maintained people’s privacy and dignity.

People were knowledgeable about the people they supported, including their support needs as well as their life history and what was important to them. People and staff had built positive caring relationships. There were opportunities for people to engage in activities they enjoyed as a group and individually. Events were also held at the service to celebrate key dates and religious festivals.

Staff supported people as required with their nutritional and health needs, and with their medicines. Staff encouraged and respected people’s independence but also provided them with the support they required at mealtimes and with meal preparation. Staff were available to liaise with healthcare professionals on people’s behalf if they needed support accessing their GP or other professionals involved in their care. For those who required it, staff administered people’s medicines and ensured they received their medicines as required. Improvements had been made to strengthen medicines management processes and ensure good practice was followed.

There were sufficient staff to attend to people’s needs. People told us that staff stayed the required time to meet their needs. If staff were running late this was communicated with people. In addition to the scheduled visits, there were staff available to respond to people’s needs as they occurred. For example, whilst people used the communal facilities and responding when people’s pendant alarms were a