LD Care is a care home for up to nine adults who have a learning disability. They also have a range of other needs including autism. At the time of our inspection nine people were living at the home. The home is run by L D Care Limited, a private organisation, who own and manage two other care homes within the London Borough of Hounslow.

At the last inspection on 6 October 2015 we rated the service Good in all the five questions we ask and overall.

At this inspection on the 19 September 2017 we found the service remained Good. The service has continued to meet all the required Regulations and has demonstrated outstanding practice in some areas.

People were safely cared for at the service. The staff understood how to keep people safe and followed guidance around this. There were clear risk assessments outlining how to avoid harm and support people in the way they needed and the staff followed these. The staff reflected on their own practice and discussed the most effective ways to support people. As a result, there was a reduction in incidents of physical challenges and harm.

People received their medicines in a safe way and as prescribed.

There were enough staff to keep people safe and meet their needs. The staff were well trained, supported and supervised. They had opportunities to discuss their work and learn from each other. They felt they had opportunities for career development and spoke about personal achievements which they felt had been made possible through their work at the service. The staff were recruited in a way which included checks on their suitability. The staff worked well as a team and felt there was positive and useful communication with each other which benefited the people who used the service.

People were unrestricted in their movement around the service and the activities they chose to participate in. The provider had acted within the principles of the Mental Capacity Act 2005. 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.

People were supported with their healthcare needs. The staff worked in partnership with other professionals to ensure people received person centred health care and support. For example, supporting them with their fears and anxieties to be able to access the health care they needed.

People's nutritional needs were being met and the staff had worked hard to support people to achieve healthy weights and make positive choices about the food they ate.

The staff were kind, caring and thoughtful. They respected people's individuality and displayed empathy when offering support. People living at the service had complex communication needs and the staff had taken great care to understand these individual needs and ensure that people had information in a way which they understood and felt comfortable with. The staff were patient and did not rush people. They had adopted nationally recognised good practice techniques to develop their own understanding of what people were trying to convey. The time and dedication spent by staff in this area had resulted in people expressing themselves in ways they had not before and being able to accept support with their personal physical care needs which they had previously resisted.

The service adopted an exceptionally person centred approach. People's individual needs and preferences were clearly recorded and the staff knew them well. The staff reflected on their work and understood how people were feeling. They provided support at a pace which people felt comfortable with. Therefore they were able to help people to overcome fears and achieve personal objectives. People had learnt new skills and had developed their independence and confidence.

There was a positive and open culture where people felt listened to and valued. People's representatives and staff felt the service was well managed and

The inspection took place on 6 October 2015 and was unannounced.

The last inspection of the service took place on 15 December 2014 when we identified no breaches of Regulation.

LD Care is a care home for up to nine adults who have a learning disability. They also have a range of other needs including autism. At the time of our inspection nine people were living at the home. The home is run by a local organisation L D Care Limited, who own and manage two other care homes within the London Borough of Hounslow.

There was 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 and associated Regulations about how the service is run.

The risks people experienced had been assessed and there were plans to minimise these.

The staff undertook safeguarding training, procedures were available and the provider had taken steps to safeguard people from abuse.

People received the medicines they needed.

There were enough staff to meet people’s assessed needs and the recruitment procedures were designed to make sure the staff were suitable to work with vulnerable people.

People’s capacity to consent had been assessed and they were supported to make decisions about their own care. Where people were unable to consent, decisions about their care had been made in a lawful way and in their best interest.

The staff had the training and support they needed to care for people effectively

People’s health needs were assessed, monitored and met.

People had the right food and drink they needed to stay healthy.

People had good relationships with the staff. The staff were kind, caring and polite.

People’s privacy and dignity were respected. People’s care was planned and met in a person-centred way which reflected their needs and wishes.

People were able to make a complaint; these were appropriately investigated and responded to.

The provider, manager and staff undertook audits on the service which identified risks and led to improvements.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014. The inspection took place on 15 December 2014 and was unannounced. The inspection was carried out by one inspector.

We last inspected the service on 10 June 2014. At this inspection we found people were not sufficiently protected from the risks of inappropriate care and treatment because the medicines were not handled appropriately. We also found the provider could not guarantee that people were cared for, or supported by, suitably qualified, skilled and experienced staff. The provider told us they would make the necessary improvements by 31 July 2014. We visited on 15 December 2014 to see if the improvements had been made.

We spoke with four members of staff including the registered manager. We met five people who lived at the home, but they were not able to tell us about their experiences of living there. We looked at records relating to staff recruitment, training and supervision, how medicines were stored and records about medicines. We saw that people appeared relaxed and comfortable, the staff were kind and caring towards the people they were supporting. Medicines were appropriately managed and the recruitment procedures ensured that the suitability of staff was checked before they started working in the home.

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?

The service was not always safe. People’s needs were assessed and plans were in place to meet these needs. There were enough staff on duty to meet people’s individual needs. The environment was clean and well maintained and there regular were checks on the safety and suitability of the building and equipment. However, people’s medicines were not being managed in a safe and appropriate way. Therefore they were at risk of receiving inappropriate care or treatment.

Is the service effective?

In general the service was effective. People’s health and care needs were assessed and planned. The provider had made improvements to the way in which people’s care was planned and delivered. People were supported by a range of different health care professionals. However, the provider’s failure to effectively manage people’s medicines put people at risk.

Is the service caring?

The service was caring. The staff were kind, polite and respectful towards people. They communicated clearly and checked people had understood them. One of the external professionals who we spoke with told us they thought the staff showed genuine fondness towards the people they were caring for. There was clear information for the staff so they knew about people’s individual needs and choices. Families of people living at the home told us they felt the service was very caring.

Is the service responsive?

The service was responsive. The provider had listened to the concerns we had identified at the last inspection and had taken action to put these right. The professionals who we spoke with told us the service responded to the suggestions they had made and this had helped to ensure people’s needs were being met. Where people had experienced a change in their needs the service had responded by adapting the care they provided, for example people’s diet had been changed to incorporate recommendations from the dietitian.

Is the service well-led?

There was a registered manager at the service. She demonstrated a good knowledge of the people living at the home and their individual needs. The staff who we spoke with told us they felt supported. They were aware of their responsibilities and accountabilities.

The provider had an effective system to regularly assess and monitor the quality of the service that people received.

We met people who lived at the home. They were not able to tell us about their experiences but we saw they appeared comfortable and content. During our visit, they spent time in their rooms and communal areas taking part in a range of different activities. We spoke with two relatives of people who live at the home. They told us that they were happy with the care and treatment their relatives received. One healthcare professional who worked with people living at the home told us that people’s needs were met. Another healthcare professional told us that they had seen some improvements in people’s health and wellbeing and that some staff were very good at meeting people’s needs.

We last inspected the home on 30 August 2013. We found that records had not always been accurately completed. The provider told us they would make sure these were accurate by 11 October 2013. At this visit we found that although some improvements had been made, some of the records were still inaccurate and therefore people were put at risk of unsafe and inappropriate care.

There had been improvements in the health and wellbeing of people who live at the home. However, not all of their needs were met. Sometimes the staff did not take into account their choices or respect their privacy and dignity.

The provider had not always carried out sufficient checks on staff suitability. There were not always sufficient staff on duty to meet the needs and ensure the health and safety of people who live at the home.

The provider undertook a range of regular checks to monitor health and safety. However, they did not have sufficient checks to ensure that records were appropriately maintained or that people’s needs were met with dignity.

The Registered Manager is also the owner of the service. The staff told us that he did not manage the service on a day-to-day basis, as this was delegated to another manager for the service. The manager at the time of our inspection told us they had been in the position since May 2013. This person is referred to as the manager in the report.

We were unable to speak with most of the people who use the service as they had complex needs and were unable to share their experiences with us. Therefore we used a other methods to understand people’s experiences such as observation and we spoke with the local authority care managers of five people who use the service. We contacted two people's relatives. We also spoke with a behaviour analyst who had been enlisted by the home to provide support.

We saw that the people who use the service and the staff had developed positive relationships with each other and there was a relaxed atmosphere within the home. The relatives were pleased with the service and told us about how their relative enjoyed living there. They said people were always well presented and they were provided with adequate activities. Some of the care managers we spoke with said they felt there should be more activities for people.

We found the service did not maintain all records relating to the management and running of the service, in accordance with legal requirements. We found that this was affected by the lack of management oversight of the home.

People who use the service have complex communication needs and we were not able to hear their views about the service directly. We observed staff supporting people in the home and spoke to a relative of a person who lives there. We also spoke to healthcare professionals who have had an involvement with people who use the service.

The relative we spoke with told us that staff at the home treated their family member with respect and maintained their dignity. They said that staff had worked hard to understand their family member’s needs and wishes so that they could provide support in the most appropriate way. The relative also told us that the home consulted and involved her when important decisions about her family member’s care were being considered.

The healthcare professionals we spoke with confirmed that staff provided support in a manner that maintained the dignity and promoted the rights of people who use the service. They told us that the service is managed effectively and that people who live at the home receive good quality care.