We undertook an unannounced focused inspection of Support for Living Limited - 25/27 Haymill Close on 6 November 2018.

This inspection was carried out to check that improvements to meet legal requirements after our comprehensive inspection on 10 and 12 April 2018 had been made. We inspected the service against two of the five key 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.

At our last inspection we found that two bathrooms were not maintained to a good standard of cleanliness. In addition, equipment was stored in an unsafe manner in the bathrooms. Therefore, we found a breach of the regulations with regard to premises and equipment. Following the last inspection, we asked the provider to complete an action plan to show what they would do to meet the regulation they were breaching. At this inspection we found that measures had been put in place to ensure that the bathrooms were maintained in a clean manner. Appropriate alternate arrangements had been made for the storage of equipment. The quality assurances systems in regard to monitoring the safety and quality of the premises had also been improved

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

Support for Living Limited - 25/27 Haymill Close 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. The care home accommodates six people with a learning disability, some of whom may have mental health needs, in one adapted building. The bedrooms and communal facilities are on the ground floor and there are several spacious lounges, dining rooms, two kitchens and bathroom facilities. There was an enclosed safe garden for people’s use. At the time of our inspection five people lived at the home.

The provider for Support for Living Limited - 25/27 Haymill Close is Support for Living Limited under the brand name of Certitude. In this inspection report we will refer to the provider as Certitude.

The care service has been developed 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.” Registering the Right Support- CQC policy

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.

The service was clean throughout and staff were observed to use personal protective equipment appropriately to avoid cross contamination.

The medicines procedure had been reviewed since our last inspection and we found that medicines were stored and administered in a safe manner by staff. Regular medicines audits were undertaken by the registered manager to check medicines were administered and recorded correctly.

The registered manager assessed staffing levels to ensure there were enough staff to meet people’s support needs. Certitude’s recruitment procedures had been followed to ensure the safe recruitment of staff.

Staff and the registered manager could tell us how they would recognise signs of abuse and knew how to report any concerns to the appropriate authorities. The regist

This inspection took place on 10 and 12 April 2018. The inspection was unannounced.

At our previous inspection on 18 and 19 December 2015 we found that the service was Good overall but there was a breach of the regulations in relation to Safe care and treatment. This was because medicines were not always stored and administered in a safe manner. We undertook a focused inspection on 21 November 2016 and we found the regulations had been met as the provider had put systems in place to ensure the safe administration of medicines.

Support for Living Limited - 25/27 Haymill Close 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. The care home accommodates six people in one adapted building. The bedrooms and communal facilities are on the ground floor and there are several spacious lounges, dining rooms, two kitchens and bathroom facilities. There was an enclosed safe garden for people’s use.

The provider for Support for Living Limited - 25/27 Haymill Close is Support for Living Limited under the brand name of Certitude. In this inspection report we will refer to the provider as Certitude.

There was not 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. However, a manager had been appointed in January 2018 following the previous registered manager leaving the service. The manager was in the process of registering with the CQC.

During our visit we found that two bathrooms were not maintained to a good standard of cleanliness. In addition, equipment was stored in an unsafe manner in the bathrooms. Therefore, we found a breach of the regulations regarding safe care and treatment. You can see what action we told the provider to take at the back of the full version of the report.

Following the inspection, the manager took prompt action to address these concerns.

Certitude had systems in place for auditing the service to ensure a good standard of service delivery. However, the health and safety audit and environmental checks had not been completed to a robust standard as they had not identified and addressed the above concerns. The management team provided assurance that they would address this concern.

Medicines were administered in a safe manner, although we noted a minor discrepancy in that a medicine was treated as a controlled drug when it was not. This was rectified immediately by the manager.

The manager assessed staffing need and ensured there were enough staff to manage people’s care. There had been some changes in the staff personnel and the manager was actively recruiting to create a stable permanent staff team. The provider used safe recruitment processes undertaking appropriate checks to ensure the suitability of staff.

People had individualised risk assessments where measures were identified to keep them safe from harm. The provider worked in line with the Mental Capacity Act 2005 and some people using the service were assessed as not having capacity regarding their care and treatment. In these instances, the manager had applied for authorisations under the Deprivation of Liberty Safeguards (DoLS) in a timely manner. Although there were some restrictions on people to help ensure their safety the care staff demonstrated they offered people choices and supported them to make their own decisions whenever possible.

People were supported to access appropriate health care and staff supported people to eat and drink healthily. When people required assistance to eat care staff followed speech and therapy guidelines to

We carried out an unannounced comprehensive inspection on 18 and 19 December 2015. We found a breach of a legal requirement as although there were systems in place to ensure safe medicines administration, these were not always effective and medicines were not always safely administered or stored.

After the inspection, the provider submitted an action plan detailing what they would do to meet the legal requirement in relation to the breach.

We undertook this unannounced focused inspection on 21 November 2016 to check that the provider had followed their plan and to confirm that they now met the legal requirement. This report only covers our findings in relation to the requirement. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Support for Living Limited - 25/27 Haymill Close on our website at www.cqc.org.uk.

25/27 Haymill Close provides care for up to nine people with a learning disability. The provider is Certitude, which has a number of supported living homes in London providing support for people with learning disabilities, autism and mental health needs. At the time of our inspection there were six people living at the service.

The registered manager had been in their role since 2014. 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.

At our focused inspection on 21 November 2016, we found that the provider had followed their plan of action, dated 9 February 2016 and the legal requirement had been met.

Staff were supported to have the skills they required to administer medicines safely through training and team meetings.

Since the last inspection, lockable cabinets had been purchased to safely store medicines in and the registered manager was in the process of ordering a separate refrigerator for medicines.

The medicines administration records were filled out correctly except for one entry which did not record the time a PRN (as required) medicine was administrated.

The GP had signed their approval for the medicines to be administered covertly to people who did not have the capacity to consent.

The service had audits in place both internally and externally to check how medicines were being administered and to undertake stock checks of medicines at least monthly to ensure people were safely receiving their medicines. Consequently, the systems had improved and errors were minimal.

This inspection took place on 18 and 19 December 2015 and was unannounced. At the last inspection on 1 May 2014 we found the service was meeting the regulations we looked at.

Support for Living Limited - 25/27 Haymill Close is a care home which provides accommodation and care for up to nine adults with a learning disability. At the time of our visit there were six people using the service.

The accommodation consists of two flats with three rooms each and is laid out over one floor.

Each person had their own bedroom and can access the communal facilities such as a lounge, dining room, kitchen and garden. The flat on the first floor had been converted into the staff office and was not used as living space. “We have requested that the registered manager submits a formal request to the Care Quality Commission to reduce the number of places offered from nine to six”.

There was 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 visit we spoke to the deputy manager, area manager, three care workers and four family members. The registered manager was not available during our visit.

The majority of people using the service were unable to share their experiences with us due to their complex needs and ability to communicate verbally. So, in order to understand their experiences of using the service, we observed how they received care and support from staff. To do this we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

We looked at records which included three people’s care records, training information, and other records relating to the management of the service. After the visit we contacted external professionals and asked them for their views and experiences of working with the service.

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

There were systems in place to ensure safe medication administration, however these were not always effective and medication was not always safely administered and stored.

People were protected from harm and abuse. Staff had up to date safeguarding training and knew how to protect people if they suspected people were at risk of abuse.

Risks were regularly assessed and risk management plans were put in place to minimise the risk of harm and guarantee people’s safety.

There were systems in place to ensure people lived in a safe environment. Staff received relevant training and knew what to do in case of an emergency.

There was an effective and roust recruitment process in place which ensured that only staff who were suitable to work with people who used the service were appointed

Staffing levels were sufficient to meet people’s general needs. However, distribution of duties and skills amongst them were not always sufficient to meet the needs of people using the service. The management team were aware of the issue and were working towards resolving it.

Staff received in-depth training to ensure they had the knowledge and skills to support people using the service. The registered manager had systems in place to guarantee that staff’s personal development continued and that all training was up to date. Relatives told us they had confidence in staff and they were happy with the support offered to their family members.

Staff received ongoing support in the form of one to one supervision and regular team meetings.

Staff had a good awareness of the likes, dislikes of people using the service. Family members described them as “knowing everything about their loved ones”.

There were good links with exte

We met five people using the service, spoke with two relatives, one healthcare professional and six members of staff.

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 caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

This is a summary of what we found-

Is the service safe?

People using the service were supported by staff who had been checked and were of a suitable character because the vetting and recruitment practices used by the service were robust and safe. Overall the environment was safe, well maintained and equipment in the home had been maintained and serviced regularly.

Risks were assessed and reviewed regularly so that people’s individual needs could be met safely. Detailed support plans were in place, which contained information about the support and care needs of people and how they wanted to be cared for. People or their representatives were involved in making decisions about their care and how they wanted to be cared for. We saw that people and their representatives were involved in developing and reviewing their support plans. A relative we spoke with said “my family member is completely safe at the home”.

People’s human rights were respected. Staff understood the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. We saw evidence that this had been put into practice and where required best interest decisions had been made where a person did not have capacity to consent. The healthcare professional we spoke with confirmed the service regularly sought advice and support where there were concerns regarding people’s ability to consent to care and treatment.

Is the service effective?

During our inspection we saw that people looked happy, were well cared for and were treated with dignity and respect. Two relatives we spoke with said the quality of care provided was of a high standard and staff had a good understanding of people’s needs. Information we viewed showed us that staff monitored people’s health and social care needs and sought advice from other professionals as required.

Equipment was available to meet people’s individual needs and promote their independence. Staff we spoke with told us they had received training on how to use the equipment available to maintain people’s safety.

Is the service caring?

The service was good and caring. Support plans we viewed detailed people’s individual preferences, likes and dislikes. Relatives we spoke with told us staff were familiar with people’s needs and how best to support them. Comments we received included “I could not speak more highly of the home”, “If I had any complaints whatsoever I would go to the manager or beyond” and “they are very good, they respond to people’s needs”.

From our observations we saw that staff interactions were professional and respectful. Where individual people displayed behaviour that challenged the service, staff managed the situation appropriately and promoted people’s dignity and respect.

Is the service responsive?

The service responded to people’s changing needs. People’s needs were regularly reviewed and we saw that the staff responded to any changing needs. For example we saw that appropriate referrals were made when a person had swallowing difficulties. The healthcare professional we spoke with told us the staff made appropriate referrals when people’s health needs changed and that people were supported to have an annual health check with their GP.

Both relatives we spoke with said the service helped support their family members to maintain family relationships.

Is the service well-led?

Arrangements were in place for assessing and monitoring the quality of the service. We saw the provider obtained feedback from people and their representatives on the quality of the service, care and support so they could make improvement to the service. Both relatives we spoke with said they were confident to raise any concerns they had, and felt that they would be listened to. Staff we spoke with told us there had been recent improvements to the service and felt supported to raise any concerns with the management team. Accidents and incidents were monitored centrally by the provider, so that any trends or patterns could be identified and addressed to prevent reoccurrence of similar incidents.

The service had an effective system to manage accidents and incidents and learn from them so they were less likely to happen again.

During our visit we met five people who used the service, spoke with six members of staff and one relative.

The previous inspection visit on 21 December 2012 had found that people using the service did not receive the care and support that was detailed in their support plan, that staff did not have up to date information and guidance to follow in the event of an allegation or suspicion of abuse and there was insufficient staff on duty to meet people’s needs.

During this inspection we found that the provider was complying with the outcome areas we assessed.

We observed staff treating people with respect and maintaining their dignity. Improvements had been made to ensure that people received the care and support that had been planned. A relative we spoke with told us that “the staff are absolutely wonderful, I cannot speak highly enough of them”.

Improvements had been made to ensure that staff had up to date information and guidance about safeguarding people. A relative we spoke with told us that their family member was “safe and secure” and that they had “100% no worries “.

Appropriate arrangements were in place for medicines management.

At this inspection we found that improvements had been made to ensure that there were enough staff on duty which enabled people using the service to access community and leisure activities

During this inspection we spent time with all six people using the service. Although most people were not able to communicate verbally, one person told us they liked living in the home and another person said they went out with the staff.

We saw that some staff knew the people using the service well and understood their care needs and how they communicated their preferences. All staff were seen to treat people using the service with respect. We saw that some people using the service received a lot of staff support and time while other people were not always supported appropriately. Some people using the service spent extended periods during the day with no staff attention or interaction.

When we last inspected the service we saw that improvements were needed to the decoration and furnishings in the home. During this visit we saw that these issues had been addressed and the home offered a good standard of accommodation to people using the service.

There were procedures in place for dealing with complaints and these had been produced in alternative formats to make the information easier for some people using the service to understand.

Staff working in the home were not up to date with the provider's policy and procedures for safeguarding adults. People could therefore be at risk until refresher training is provided as staff might not know the action to take to safeguard people if there were allegations of abuse.

The majority of people living at the service had profound learning difficulties and were not able to tell us directly about the care they received and experienced. Two people using the service had some verbal communication and they told us they were “happy”.

To help us to understand the experiences people have we observed what was going on in the home, looked at how people spent their time and the type of support they get. From our observations we found people were receiving care, treatment and support that met their individual needs and preferences. We saw that staff had a good understanding of people's individual needs and capabilities.

We observed that people living at the service had choices in all aspects of their daily living. They had their privacy and dignity respected. People were provided with information that supported and enabled them to make decisions about their care and treatment. From our observations we saw that people appeared to be happy and content with the support they were receiving.