This inspection of Willow House took place on 28 November 2018. It was an announced comprehensive inspection. At the last inspection in November 2017 the service was not meeting two regulations under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This scheme provides care and support to older people and people with mental health needs living in specialist ‘extra care’ housing. Extra care housing is purpose-built or adapted single household accommodation in a shared site or building. Willow House is a purpose-built block of flats on three levels, containing 40 flats. People remain independent and live in their own flat within their community. 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. There were 38 people living at the scheme at the time of this inspection.

The service had a registered manager in place. 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 scheme had auditing systems to ensure they met legal requirements. However, these had not identified the shortfalls we identified during our inspection. The scheme was not consistently undertaking mental capacity assessments or escalating concerns relating to capacity to relevant authorities.

Joint working arrangements and shared services promoted co-ordinated person-centred care. However, we judged the scheme still needed to develop further links with the local authority in managing admissions. We judged that more joint working could improve access particularly in situations where people could choose their own care provider from an external agency rather than the on-site care team if they so wished.

At this inspection we found that improvements had been made. Risks were being planned for, managed and mitigated appropriately. Risks associated with people's care and support needs had been identified in care records along with guidance about how to support people to keep them safe.

The scheme had taken steps to respond to concerns we raised in the previous inspection about the management of risk for people with dementia. The scheme was now offering more tailored assistive technology to support individuals to complement support from care workers.

The scheme had clear systems to keep people safe and safeguarded from abuse. All care workers received up-to-date safeguarding and safety training appropriate to their role. Staff checks were also carried out on recruitment and on an ongoing basis. Disclosure and Barring Service (DBS) checks were undertaken where required.

There were sufficient care workers on duty to meet people's needs and keep them safe. Care workers worked in an unhurried way and met people's individual needs. Rotas suggested there were sufficient staff deployed to support people. Extra care workers were made available if needed.

There were appropriate systems for safe handling of medicines, health and safety and infection control. These systems were subject to regular auditing. The management had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Although there were elements of good practice in the application of the Mental Capacity Act 2005, this was not across the board. Improvements had been made relating to the use of liberty restricting measures such as location devices, door sensors and the use of verbal distraction techniques. However, decisions about capacity were not consistently taken and reviewed in a structured way. We judged that further improvements were required in this area.

Care workers received supervision

We undertook an announced focused inspection of London Care (Willow House) on 27 November 2017. We inspected the service against three of the five questions we ask about services: is the service well led, is the service safe and is the service effective. We undertook this inspection to check that London care (Willow House) had followed their plan to improve the service after our inspection of 4 July 2017 and because we had received information about the death of a person who had lived at Willow House. .

No risks, concerns or significant improvement were identified in the remaining Key Questions through our on-going monitoring and during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

London Care (Willow House) provides care and support to older people and people with mental health needs living in specialist ‘extra care’ housing. Extra care housing is purpose-built or adapted single household accommodation in a shared site or building. Willow House is a purpose built block of flats on 3 levels, containing 40 flats. People remain independent and live in their own flat within their community. 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. London Care (Willow House) provides personal care to 40 people living at Willow House via an individual contract with the host local authority. A separate provider manages the housing element of the service.

The service had a registered manager in place. 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.’

We found that the arrangements to assess, monitor and improve the quality and safety of the service were not fully effective. The audit process had not identified some issues we saw such as absence of risk assessments and mental capacity assessments.

At our inspection of 4 July 2017 we had identified concerns about the safety of some of the people living at Willow House including whether the setting was suitable. At this inspection we discussed this with the provider at and after the inspection and we were provided with assurance that London Care (Willow House) was able to discuss such matters with the other partners and takes action as needed. However, we found that London Care (Willow house) needed to do more to work with others to address risks to people when they left Willow House. For example, we identified that five people using the service needed a high level of monitoring in relation to disorientation.

Some people at the service may have lacked capacity to make specific decisions but the service had not carried out mental capacity assessments. Some measures to protect people had been put in place if the service had concerns about people leaving the premises unsupervised. However, there was no record in people’s care records of whether or not people had capacity to agree to this. This was necessary to make sure if there was any form of restriction, this was done in a safe and correct way.

We have made a recommendation about the application of Mental Capacity Act 2005 in relation to people living in extra care housing.

We undertook an announced inspection on 4 and 7 July 2017 of London Care (Willow House). London Care (Willow House) is registered to provide the regulated activity personal care.

London Care (Willow House) is an extra care housing service providing personal care to people. London Care (Willow House) is a purpose built block of flats on 3 levels, containing 40 flats. The service provides support to older people and people with mental health needs to remain independent and live in their own flat within their community. At the time of inspection the service provided personal care to 41 people who lived in flats in London Care (Willow House).

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 2008 and associated Regulations about how the service is run.

We found the premises were clean and tidy. Maintenance checks were conducted by a housing association. However during the inspection, we found aspects of the building that needed improvement. The building was having continuing issues with bed bugs, mice and rats. Fixtures that controlled windows in communal areas were not secure which could be a potential safety hazard for people using the service. Furthermore there was a lack of information to show what support each person would need in the event of a fire.

Records showed the provider had taken some action to address the concerns raised and during the inspection, records confirmed the housing association had been contacted by the registered manager for them to address the issues raised.

Staff we spoke with had an understanding of the principles of the Mental Capacity Act (MCA 2005). Capacity to make specific decisions was recorded in people's care plans. Although we saw some people going out into the community, there were some people using the service who could be at risk in the community due to their lack of capacity.

People's health and social care needs had been appropriately assessed. Care plans were person-centred, and specific to each person and their needs. Care preferences were documented and staff we spoke with were aware of people's likes and dislikes. Care plans were reviewed and were updated when people's needs changed.

People using the service informed us that they were satisfied with the care and services provided. Relatives also told us that they were confident that people were safe.

Staff had received training in safeguarding adults and knew how to recognise and report any concerns or allegations of abuse.

Systems were in place to make sure people received their medicines safely. Arrangements were in place for the recording of medicines and for their storage, administration and disposal.

Staff had been carefully recruited and provided with induction and training to enable them to support people effectively. They had the necessary support, supervision and appraisals from management.

There were suitable arrangements for the provision of food to ensure that people's dietary needs were met.

Staff were informed of changes occurring within the service through daily handovers and staff meetings. Staff told us that they received up to date information and had an opportunity to share good practice and any concerns they had at these meetings.

There was a management structure in place with a team of care workers, senior care workers, team leader, registered manager and the provider. Care workers spoke positively about the registered manager and the open and transparent culture within the service.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered manager to take at the back of the full version of this report.