This inspection took place on 15 March 2018 and was announced. We gave the service 48 hours’ notice of the inspection as the service is community based and we needed to ensure the registered manager would be available

Sanctuary Homecare Ltd provides care and support to people living in an ‘extra care’ housing scheme. The scheme is referred to as Exning Court by people, relatives, staff and the provider. We have also referred to the scheme as Exning Court in our report. Extra care housing is purpose built or adapted single household accommodation in a shared site or building. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people’s personal care and service. Not everyone living at Exning Court received the regulated activity. On the day of our inspection 28 people were receiving a personal care service.

Exning Court consists of 34 self-contained flats. There are eight two bedroom apartments and 26 one bedroom apartments built around a central courtyard. The service is situated in a quiet rural area on the edge of the village of Exning near Newmarket. The service provides support to people to live in their accommodation, with their own tenancy agreements. The aim of the service is to provide people with support they need to live as independently as possible. The people who used the service received individual bespoke support hours depending on their assessed needs.

At the last inspection in July 2016, we found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We were concerned because there was poor recording of peoples changing needs in their care plans and the provider was failing to keep an accurate up to date contemporaneous record of the care given. We asked the provider to take steps to improve and complete an action plan to show what they would do and by when to improve the key question of responsive. At this inspection we found improvements had been made.

There was a registered manager in post at the time of the 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.’

There were sufficient staff to meet people's needs and spend time with them. People received their care when they wanted it and consistently, there were no missed care calls. Risk assessments were carried out and promoted positive risk taking which enabled people to live their lives as they chose. People received their medicines safely.

People were cared for by staff who received appropriate training and support from their line managers. Staff skills were regularly assessed through spot checks to ensure they knew how to support people in a safe, respectful and effective way.

The service worked within the principles of the Mental Capacity Assessment 2005 (MCA) and staff sought people's consent before entering their home and supporting them.

The staff were caring and kind and had developed good relationships with people using the service. They engaged with people and welcomed their relatives and friends when they visited. Where needed, people were offered support to eat and drink and to prepare meals and snacks.

People's needs and preferences were assessed prior to them moving into the service. There was an assessment process in place, which involved people and ensured that people received support that met and was based on their needs and personal preferences.

The service was well-led and people were satisfied with the care and support provided. Staff said they liked working at the service because they were able to provide a high standard of care. There was a quality assurance system in place to ensure the s

We inspected this service on the 12 and 14 July 2016 and the service was given 48 hours’ notice in line with our methodology for domiciliary care agencies. We gave notice in order for the care manager to contact people using the service and ask their consent for us to visit them. We visited five people using the service. We had previously inspected this service on the 24 June 2014 using our old methodology. The service was non-compliant with supporting workers and we made a compliance action. The provider sent us an action plan telling us how they had addressed this.

The service is split into two parts with Sanctuary housing who provide accommodation for people who may or may not have an assessed care needs. People pay a weekly charge to have staff available twenty four hours a day and a call bell system to enable people to contact staff in an emergency. Housing issues are dealt with through an on- site housing manager. In addition there is a registered manager who oversees the care hours people might have which are either contracted hours of support or non- contact time which is support provided in an emergency. On site there are 34 flats and a number of communal areas such as a communal laundry, lounge and dining area for the benefit of its residents. The housing manager was responsible for overseeing the catering arrangements where people could pay for a cooked meal on site if they wished. This report relates to the care provider.

There was a registered manager for the regulated activity of personal care. 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 experiences of the service varied with a number of people experiencing difficulties in a number of different areas: including failures in the heating and hot water, issues around the availability of a chef during the week and weekend and people not always given sufficient notice of when a hot meal was not going to be available so people could make alternative arrangements. There were concerns about activity level and general maintenance issues. All these issues related to people’s housing contract and not their care contract so we could not consider these as part of our inspection. However these issues had the potential to negatively impact on people’s health and a greater cohesion between housing and care matters would improve people’s overall.

People spoken with were happy with the care they were provided with and benefitted from a regular staff team who were familiar with their needs. Staff were based on site so could be flexible in their approach. People had set visit times but staff demonstrated that they were flexible and responded to changing needs. Some people spoken with were concerned that at night there was only one member of staff and felt this to be inadequate. We were given examples of why people felt this was inadequate and noted that a number of people had high dependency levels. Two people required two staff to assist with manual handling. People had appropriate equipment in place to help maintain their skin integrity but staff were unable to change their position at night.

People were supported to remain healthy but we could not always see clear monitoring of people’s needs. We felt this was a records issue as some records were ambiguous and care plans were not always updated when people’s needs changed.

Staff were trained for their role and felt well supported. Staff had completed all the training essential to their role but not all staff were sufficiently familiar or confident with the needs of people with long term health conditions such as diabetes. The manager said they would address this.

Staff recruitment processes were sufficiently robust which

During our inspection on 1 November 2013 we spoke with five people who received care from this service. In addition we spoke with four members of staff, the manager, and one visiting professional.

People told us they were encouraged to express their views and were involved in making decisions about the way their care was provided. They said that they felt staff listened to them and respected their views when providing personal care.

People experienced care and support that met their needs and protected their rights. One person told us they and the staff, “work with one another” to ensure their needs were met. Another person told us, “The staff are very good. You couldn’t get better.”

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

People were cared for by staff who were supported to deliver care safely and to an appropriate standard. One person commented that, “All the staff seem to know what they are doing.” The other people we spoke with agreed with this view.

The provider had effective systems in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others and to assess and monitor the quality of service that people received.

Our inspection of 15 November 2012 found that people’s needs were not being assessed and care and treatment was not being planned and delivered in line with their individual care plan. Allegations of abuse were not be responded to appropriately and we found that there were not enough, skilled and qualified staff working in the service. The provider wrote to us on 18 January 2013 telling us the actions they were taking to address these issues. This inspection took place to check if improvements had been made. We looked at four care plans, daily records and pre admission assessments. These had been updated and reflected people’s needs. They had been written in the first person and were concise and informative. There were systems in place to regularly audit records and make improvements where required. Records showed us how staff were being held accountable for the care they were providing.

The numbers of incidents affecting the well being and, or safety of people using the service had been significantly reduced and we saw how the manager was recording and responding to any allegations of possible abuse. This meant people using the service were protected.

Staffing levels had improved and staff were being properly vetted. Staff supervision was happened regularly. Spot checks on staffs practice were being carried out and underperformance was managed through increased supervision and, or training. Staff training had been brought up to date.

We spoke with five people who used the service. Two people told us that the service had improved over the last two months. They said there were more permanent staff employed now, which meant the service was less reliant on agency staff. One person said they had several missed calls. One person told us, “We have regular residents meetings and brought up the issue of not enough staff every time. The times of my calls still fluctuate.“ Another person said, “Suggestions raised are acted upon. They provide a reliable service.” Another said “Staff are kind and respectful and I can have a laugh with them.”

We spoke with three staff and looked at training and recruitment files. Gaps in record keeping were identified in relation to the employment of outside agency staff which posed a risk to people using the service.

We inspected five care records for people using the service. Records did not clearly describe people’s needs or what they were able to do for themselves. We were informed of situations when people had not had their needs met because staff were unfamiliar with them.

We inspected records relating to the management of the business and safeguarding records. These did not accurately record what actions the service had taken to ensure people’s well being and safety or identify what improvements were necessary. This meant that we could not be assured that people were fully protected from harm.

We inspected the service over two days. On 24 June 2014 we visited five people using the service in their own homes and a family member. On 25 June 2014 we visited the office to see how the business was being managed.

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 safe, is the service effective, is the service caring, is the service responsive, is the service well led? Below is a summary of what we found.

Is the service safe?

We found that people who used the service were receiving safe and appropriate care and support. The manager told us that some people’s needs had changed since they had first started to use the service and their needs were being monitored to ensure the service was able to continue to meet their needs. The building was situated near a busy road which could pose a risk to people who might be confused about their surrounding as there were no restrictive measures in place to ensure people were safe.

Staff received training to give them the skills to recognise and respond promptly and effectively to any evidence or suspicion of abuse.

The manager said everyone using the service had capacity to consent to their care. We saw that people were consulted about their care and had given their consent to be helped with tasks they were unable to do for themselves.

Staff received adequate training and support to enable them to deliver care to people safely. People’s care plans provided information to staff about people’s individual risks in relation to manual handling and, or other care needs.

The provider had robust recruitment process in place that safeguarded people from staff that were not suitable to work with vulnerable people.

Is the service effective?

The people who used the service were full of praise for staff and the support they received. We saw strong, effective leadership and systems in place to measure the effectiveness of the service delivery. People were involved and consulted about their care to ensure it was centred around their needs.

Concerns about the service or concerns about people’s well- being were recorded and records were kept about what action had been taken. This meant the service was effective in dealing with concerns and events.

Is the service caring?

We found that staff provided sensitive and compassionate care, with kindness, dignity and respect. Support to people was provided with a good deal of humour and kindness. Every one we spoke with were happy with the staff. One person said, “One carer rushes me, but I can handle that."

Is the service responsive?

The service responded to people's changing needs. Care plans were updated as people's needs changed. People told us that staff met their needs and gave us examples of where staff had responded to changes in their daily needs.

Is the service well led?

People’s needs were reviewed in an on-going way and staffing was flexible to suit people’s needs. Care staff received regular supervision and direct observations of their practice to ensure they were competent with the task they were carrying out. Staff received training which was robust and evaluated to make sure it gave them the knowledge they needed to undertake their role.