We undertook an unannounced focused inspection of Horton Street on 09 January 2019. This inspection was done to check that improvements to meet legal requirements planned by the provider after our previous inspection on 19 September 2018 had been made.

We inspected the service against two of the five questions we ask about services: is the service well led and is the service safe. This is because the service was not meeting some legal requirements. No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or 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.

At our previous inspection on the 19 September 2018, the provider was found to be in breach of Regulations, 13 and 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014 and was rated as requires improvement overall. This was because the provider's audits and systems did not identify the shortfalls that we did. At this inspection we found that these regulations had been met. The providers overall rating has been changed to ‘Good’.

Horton Street is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Horton Street provides care and support for a maximum of six people. There were five people living at the home at the time of the inspection.

There was a registered manager in post at the time of our 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 were protected from risks associated with their health and care needs because risk assessments and associated care plans were developed, reviewed and monitored. Staff were aware of the risks to people when supporting them. Staff had a good understanding of safeguarding and where to report concerns.

Staff were caring and treated people with respect. There was a friendly, calm relaxed atmosphere within the home. People were supported by sufficient numbers of staff who had the knowledge and skills they required to care for people safely and effectively. People received support from staff to take their prescribed medicines. Systems and processes were in place to ensure medicines were managed safely.

Staff understood their responsibilities in relation to hygiene and infection control. There were systems in place to monitor the quality of the service and areas needing improvement were acted on.

We carried out this unannounced inspection on the 19 and 24 September 2018.

Horton Street is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Horton Street provides care and support for a maximum of six people who are. There were six people living at the home at the time of the inspection.

We checked to see if the care service had been developed and designed in line with the values that underpin the ‘Registering the Right Support’ and other best practice guidance. These values include choice, promotion of independence and inclusion. We found that people living at Horton Street were able to live in a homely environment that had been created to meet their needs.

At our previous inspection February 2016 we rated the service as ‘good’ in four of the five questions we ask and good overall. At this inspection we found the service was rated ‘requires improvement’ in two of the five questions and ‘requires improvement’ overall. This was because we identified breaches of the Health and Social Care Act 2008 (regulated Activities) Regulations 2014. You can see what action we plan to take at the end of this report.

There was a registered manager in post at the time of our 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 systems in place to monitor the quality and safety of the service provided. However, these systems were not effective as they had either not identified issues we found at our inspection or the registered manager and provider had failed to act promptly on their own findings. People were not always protected from the risk of harm because processes in place were not consistently managed and were not robust. Risks to people’s safety were not always acted on in a timely way.

Staff had received training in relation to protecting people and systems were in place however, these had not been effective. Incidents that had occurred in the home had not always been recognised as a safeguarding incident and had not been reported to the local safeguarding teams, police and CQC.

Staff sought consent from people before caring for them. Staff had some understanding of the principles of the Mental Capacity Act, 2005 (MCA). Where people were deprived of their liberty, processes had been followed and applications applied for.

Staff understood people’s communication needs so people could be involved in aspects of their care. People were supported to have enough to eat and drink and to manage their health care needs.

People were supported to enjoy a range of activities. People were encouraged to maintain their independence and live active and fulfilling lives. People could maintain relationships that were important to them. Relatives we spoke with felt their family member was well cared for.

Staff were caring and treated people with respect. We saw people were relaxed around the staff supporting them. It was evident that people had developed positive relationships with staff and there was a friendly and calm atmosphere within the home.

Our inspection was unannounced and took place on 16 February 2016.

The provider is registered to accommodate and deliver personal care to six people. Six people lived at the home at the time of our inspection. People lived with a profound hearing and visual impairment and also had a varied range of other needsincluding those related to a learning disability, autistic spectrum disorder, or mental health needs.

At our last inspection of August 2014 the provider was meeting all of the regulations that we assessed.

The manager was registered with us as is required by law. 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.

Some changes and more diligence was needed to enhance medicine safety to ensure people’s health and wellbeing.

The heating in the home was in need of remedial work to ensure that it worked consistently to prevent any risk of ill health due to low temperatures.

Staff received induction and the day to day support they needed to equip them with the knowledge and direction to undertake their job roles. Staff had received the training they required to equip them with the skills they needed to communicate with, and support, the people in their care.

Staff knew the procedures they should follow to ensure the risk of harm and/or abuse was reduced. Recruitment processes ensured that unsuitable staff were not employed.

Staff were available to keep people safe and there were enough staff to allow care and support to be provided flexibly and to consistently meet all people’s needs. People were supported by staff who were kind and caring.

Staff understood the requirements of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). This ensured that people received care in line with their best interests and would not be unlawfully restricted.

People were encouraged to make decisions about their care. If they were unable to their relatives were involved in how their care was planned and delivered.

Staff supported people with their nutrition and dietary needs to promote their good health.

All people received assessments and/or treatment when it was needed from a range of health care and social care professionals which helped to promote their health and well-being.

Systems were in place for people and their relatives to raise their concerns or complaints.

Relatives and staff felt that the quality of service was good. The registered manager and provider undertook regular audits to determine shortfalls or to see if changes or improvements were needed.

The inspection was undertaken by one inspector. We gathered evidence against the outcomes we inspected to help answer two of our key questions; Is the service caring? Is the service safe?

We visited the service in response to concerns that had been raised with us including medicine management and staffing levels.

We were unable communicate verbally with people who used the service due to their complex communication needs. However we carried out direct observations of staff supporting and interacting with them and we spoke with relatives of two people who lived at the home.

Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We looked at the management of people's medicines. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

We looked at staffing arrangements and found there were enough qualified, skilled and experienced staff to meet people’s needs. There had been an increased use in agency staff but the provider was taking steps to reduce their use so that people would be supported by staff who knew their needs well.

Is the service caring?

People were supported by kind and attentive staff. We saw that staff showed patience and gave encouragement when supporting people.

People's relatives told us that they were happy with the care that was provided. One relative told us, “All of the staff know my relative well and her little ways.”

We visited to follow up on our last inspection in October 2013 when we made a compliance action about records. We had concerns at that inspection that safety checks and complaints that people made were not always appropriately recorded.

Six people lived at the home on the day of our inspection. Due to people’s needs they were not able to tell us their experiences of living at the home so we observed how staff interacted with people. We spoke with three members of staff and the registered manager.

We looked around the home and saw that it was safe, clean and comfortable for people to live in. People who lived there were getting ready to go out or had already gone out to various activities within the community supported by staff.

We saw that improvements had been made to records to show that people were cared for and supported to meet their needs. We saw in records we looked at that the home and any equipment that people who lived there and staff used was safe.

During our visit we met five of the six people living in the home. As people living in the home were not able to tell us about their care we spoke to four relatives, four staff, the manager and observed the care given to people. We looked at the care records of two people.

We saw there were good interactions between the people who lived there and staff and care was provided in line with people’s assessed needs and preferences. Three of the four relatives told us that they were happy with the care provided. One relative told us, “Staff are really good. Can’t praise them enough.” The fourth relative told us they were not 100% happy with the care.

Records showed and relatives confirmed that they were involved in how their relative's care was provided.

The environment met people’s needs. Adaptations were in place and bedrooms were personalised to meet people’s needs and preferences. Some relatives told us that they felt the communal areas of the home were not homely.

Staff received training and supervision that enabled them to meet people’s needs safely. Staff told us they felt listened to and supported by the manager.

The quality of the service was monitored and people’s views were listened to.

Safety checks and complaints were not always appropriately recorded.

Our inspection was unannounced, which meant that no one knew that we would be visiting. There were six people living there on the day of our inspection. We met all the people living there but due to their needs they were unable to tell us their experiences of the home. Therefore, we spent time observing how staff interacted with and supported them. We spoke with six members of staff, the manager and the area manager and looked at two people’s records.

Staff communicated with each person in a way that they understood so they could be involved in making choices about their lives.

We observed that people were encouraged to do things for themselves, so promoting their independence skills and self esteem.

We saw that people were supported to have regular health checks to ensure their well being.

People were given opportunities to try out different activities and experience new things to develop their skills and interests.

Systems were in place to ensure that people were safeguarded from harm. We saw that people were comfortable in the company of staff.

Staff received the training they needed so they knew how to support the people living there. Staff told us they were well supported in their role.

The people living there and their relatives were asked for their views about the home and these were listened to. Audits were completed and action taken where needed to make improvements.

We carried out this review to check on the care and welfare of people using this service.

We reviewed all the information we hold about this provider, carried out a visit on 25 January 2012, checked the provider's records and observed how people were being cared for.

People were not able to tell us their experiences due to their medical conditions. We saw that information was available to show how people had been supported to express their views about things that affected them and make their decisions known.

People are supported to make decisions as much as they are able to, where they are not able to other people act on their behalf so that any decisions made are in the person's best interests.

Staff know how to support the people that live at Horton Street to ensure their well being. Staff work well with other professionals to help ensure that people's complex needs are met. People take part in a range of activities that they like to do.

Regular checks and audits of the home are done to make sure that people are getting the care and support they want and need. However there were some areas that required improvement such as the flooring in bathroom and toilet areas, broken radiator covers, flaking paint on bathroom ceilings, stained carpets in bedrooms and lounge, and a mattress which was no longer fit for purpose. It was concerning to note that these environmental risks to the health, welfare and safety of people had not been addressed considering that the damage we saw was not an issue that had occurred recently. Our findings showed a need to ensure the home's audits of quality and safety are consistently robust.