This inspection took place on 11 and 12 October 2018. It was an announced visit to the service.

We previously inspected the service in August 2017. The service was not meeting all of the requirements of the regulations at that time and was rated ‘requires improvement’. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions ‘safe’ and ‘well-led’ to at least ‘good.'

This service provides care and support to people living in two 'supported living' settings, so that they can live in their own home as independently as possible. 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 support.

The care service has 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. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

The service can provide support for up to 12 people. Eleven people were using the service at the time of our inspection. In one setting, people lived in a shared house and had their own bedroom with en-suite facilities. In the other setting, people lived in self-contained studio flats.

The service had 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 improvements had been made in the areas where the service was previously not meeting the regulations. These were in relation to medicines practice and notification of significant events.

People told us they liked living at the service. Relatives were complimentary of care. For example,

"The staff cope well with the diversity of all the different adults. Everyone seems to be happy. On the whole they do a good job caring" and "I've seen staff be patient, kind and compassionate." Some relatives had concerns people had put on weight and also about personal hygiene. The registered manager told us encouragement was given to follow healthier diets, to exercise and to attend to personal care.

People were supported to be independent at the service. They had 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 safeguarded from the risk of abuse or harm. Written risk assessments supported people to keep safe.

There were sufficient staff to meet people’s needs. They were recruited using robust procedures to make sure people were supported by staff with the right skills and attributes. Staff received appropriate support through a structured induction, regular supervision and appraisal of their performance. However, this was not the case for the registered manager. We have made a recommendation for them to receive regular supervision. There was an on-going training programme to provide and update staff on safe ways of working

Care plans had been written, to document people’s needs and their preferences for how they wished to be supported. These had been kept up to date to reflect changes in people’s needs. People were supported to take part in a wide range of social activities. Staff supported people to attend healthcare appointments to keep healthy and well.

There had not been any complaints about the service. People knew how to raise any concerns and were relaxed when speaking with staff and the registered manager.

The service was managed well. The quality of care was assessed through surveys an

This inspection took place on 22 and 23 August 2017. It was an announced visit to the service.

Stepping Stone Independent Living Ltd provides personal care support to people with a learning disability in a supported living environment. At the time of our inspection 10 people were being supported across two supported living schemes in High Wycombe.

We previously inspected the service on 1, 3 and 5 February 2016. At that inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service did not ensure it had robust recruitment processes in place and staff were not supported in their role. At this inspection we found improvements had been made to recruitment practices and staff were routinely supported by the registered and deputy manager.

At the previous inspection we found the service did not always follow the core principles of the Mental Capacity Act 2005 (MCA). At this inspection we found staff had a good understanding of how to promote people’s decision making and were aware of when a mental capacity assessment was needed.

People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice.

At the previous inspection we found there was a lack of systems in place to ensure the service was well-led. Audits undertaken did not highlight areas of concerns we found. At this inspection we acknowledged some improvements had been made. This was confirmed by what a relative told us. “[Registered manager] is the best one in a while” and “The service has improved over the years; the new manager has provided stability.” However, we found some improvement was required in the development of effective quality assurance processes. Audits undertaken by the registered manager had not identified the concern we found in relation to PRN medicines. We have made a recommendation about this in the report.

At the previous inspection we had concerns that risks posed to people had not always been identified and reduced. At this inspection we found risks had been assessed and staff had a good understanding of the remedial action required to reduce risks to people.

At the previous inspection we had concerns about the management of medicine stock and the records around as required (PRN) medicines. The service did not routinely ensure it had additional guidance for staff to follow on when they should administer PRN medicine. At this inspection we found on-going concerns about the records and practice around PRN medicines. We were unable to tell why the medicine had been given and the guidance for staff was not clear. This meant there was a danger people may have been given the medicine too frequently.

There are certain events which the provider and registered manager are required to inform us about. We checked our records and we have not been notified of at least four events when required.

The service had 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.

People told us they felt safe within the home, and had confidence in the staff team to deliver safe care. People told us they knew who to speak with in the event of a concern being raised.

People had developed good working relationships with staff. We noted there was a lot of laughter in the service. People were encouraged to be independent.

People had access to a wide range of activities of their choosing.

People had a regular meeting with a keyworker to ensure their care plan was up to date and reflected their current wants and needs.

We found an on-going breach of the Health and Social Care Act 2008

Stepping Stone Independent Living Ltd provides supported living accommodation and domiciliary care services for adults with learning disabilities and mental health conditions in High Wycombe.

This was an announced inspection and was undertaken over three days. 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.

During our inspection, we raised concerns in relation to people’s risk assessments. We found in one person’s file, they had no risk assessments relating to their placement at Stepping Stone. Care plans were not always reflective of people’s current needs and living situation.

People were not always protected from harm as the provider had poor recruitment checks in place. We found one staff member working without an appropriate disclosure and barring service (DBS) check in place. This check ensures staff are suitable to work with people using the service.

There were poor quality assurance processes in place to identify these issues.

People told us they were happy and felt safe living at Stepping Stone. We saw people were supported by staff who were kind and caring and promoted people’s independence. People were supported to access the outside community and participated in local college courses as they wished.

Although staff told us they felt supported by management and worked well as a team, we found they were not always supported effectively through regular supervision and training updates.

We found a number of breaches 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.

On our inspection of the 24 October 2013 we found the provider had failed to take appropriate steps to ensure suitable arrangements were in place for obtaining consent. This was because, where people did not have the capacity to consent, the provider did not act in accordance with the legal requirements. A warning notice was served to the provider to ensure they addressed the non-compliance. During this inspection we found this concern had been addressed.

We found where people did not have the capacity to consent; the provider was now acting in accordance with legal requirements. The home now had in place appropriate policies and procedures for staff to follow, should the need arise. Training records, showed staff had received training on the Mental Capacity Act 2005 (MCA). Both members of staff we spoke with demonstrated a good understanding of the need to obtain people's consent to care and support and the MCA 2005.

During our visit we spoke with three people who used the service and two members of staff. People we spoke with told us staff sought their consent before providing care and support. One person told us "I like going college... it's my choice." Another person said "I like art, listening to music and shopping." All the people we spoke with told us they had options to choose from, made their own decisions and which the staff respected. A member of staff who had recently started to work with the service, told us "Residents have alot to choose from; for example, they choose their outfits and what they like to eat. We encourage them, but ensure it's the person who makes the decision."

We spoke with three people during our visit. We spoke with four members of staff, which included the deputy manager. At the time of this inspection the registered manager did not work for Stepping Stone Independent Living. People told us that their needs were being met and felt the care provided was good. One person told us “I am very happy. My key worker knows me well and knows how to help me.” Another person told us “They (staff) take good care of me.” People we spoke with told us that staff asked for their consent before any care or support was given to them. One person told us "They always ask me first before they help." Another person told us "They take my permission first."

When we visited the service on the 19 April 2013, we had concerns that people were not asked for their consent before they received any care or support and action was not taken in accordance with their wishes. During this inspection where people were able to give consent, we found the provider sought their consent before people received care or treatment and the provider acted in accordance with their wishes. However, where people did not have the capacity to consent, the provider did not act in accordance with legal requirements.

During our previous inspection, we found assessments of the needs of, and risks to, people who use the service had not been reviewed and updated, to ensure their needs continued to be met. At this inspection we found the service had addressed these concerns.

People told us staff always sought their consent before carrying out any personal care or for day to day activities. For instance one person told us "The staff always ask me before helping." Another person told us "They always knock on my door and when I say they can come in they enter." However there was no consent process in place to ensure permission was sought from the service user or by a family representative before care or support was delivered. All four care plans we reviewed did not have care plan agreements in place and we noted support plans and risk assessments were not signed by the people or their representatives.

We spoke with three people who use the service. Everyone told us they were happy with the service. For example, one person said, "The care is really good here." Another person said of their carer, "My carer is very good, she is fun and very helpful." . However, we found many care plans and assessments of risks to people had not been reviewed or updated for more than a year. This meant there was a risk that the personal care provided was not meeting their needs.

People we spoke with were satisfied with the support they received and said they felt safe with the staff that provided care to them. They told us there were always enough staff around to help them and to talk to them. People were made aware of the complaints system. People we spoke with did not have any complaints about their care.

We did not speak to people specifically about the prevention and control of infections, but we did speak to them about the standard of cleanliness of their accommodation. People told us staff supported them to keep their accommodation clean and tidy. They told us they were encouraged to so some of the household cleaning with support from staff. One person said ''I look after my room but sometimes the staff help me to do it.''

People said notices were displayed in their bathrooms which showed them how to wash their hands using good hand washing techniques.

A copy of the Department of Health Code of Practice on the prevention and control of infections and related guidance had been obtained and cleaning schedules had been put in place for staff to undertake on a daily basis. The service had put systems in place to control the spread of infection. These included an infection prevention and control risk assessment with guidelines to reduce any risks, an audit tool to enable regular monitoring to determine where improvements could be made to improve outcomes for people using the service.

Infection control training had been booked for staff to attend. This was to ensure staff's knowledge and skills were kept up to date and would enable them to apply it in their work as part of their everyday practice.

People we spoke with confirmed that they were treated with respect and their dignity was maintained. They said that they were satisfied with the standard of care and support provided and were of the opinion that staff understood their needs. They told us that the staff treated them as individuals and respected their views and choices. They said that they were consulted with about any changes to their care and support and were able to make decisions and contribute to the care planning process.

People told us that they had no concerns but if they did they would either tell the manager or their key worker. They said they felt safe and well looked after.