The inspection took place on 12 and 13 June 2018 and was announced. De Lacy Gardens registered with the Care Quality Commission (CQC) on 20 April 2017 and has not been previously inspected. There were 27 people who used the service at the time of inspection.

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.

People using the service lived in their own flat in a purpose built complex and had access to care and support 24 hours a day, seven days a week. There was a communal dining area for people to use at lunchtime if they wished.

There was a registered manager in post at the time of inspection. 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’s allergies were not always recorded on the medication administration records (MARs). PRN ‘when required’ protocols were not in place to guide staff as to when these medicines should be given. Systems and processes in place to manage medicines were not always safe or effective. There was no set criteria used for any risk assessments. There was no corresponding risk score used to assess risk therefore it was not clear what people’s level of risk was. We found a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People were supported by sufficient numbers of staff to meet their needs. Staff underwent appropriate checks prior to starting work. Staff received an induction, regular supervision and training. We made a recommendation for the provider to maintain an overview of all staff training to ensure it remained up to date.

The service followed the principles of the Mental Capacity Act.

Staff involved people in making decisions about their care, support and treatment as far as possible. People told us staff understood their needs and treated them with dignity and respect. Staff gave clear examples how they respected people’s privacy and dignity.

The provider had a complaints policy and procedure. People were aware of how to make a complaint. Complaints were responded to appropriately.

Staff were happy working at De Lacy Gardens and felt supported by the management team.

Although the registered manager had begun to develop auditing systems, we found the registered manager and provider did not have a sufficient overview of the service. We concluded the provider did not have appropriate systems and processes for assessing and monitoring the quality of the service. The provider did not have sufficient systems and processes to mitigate the risks relating to the health, safety and welfare of service users.

We found a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we told the provider to take at the back of the full version of the report.