This inspection took place on 20 February 2018 and was announced. The provider was given 48 hours’ notice because the location provides a domiciliary care service and we needed to be sure staff would be available to assist with our inspection.

At the last inspection in February 2016 the service was rated Good. At this inspection we found the service remained Good.

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community. It provides a service to older adults, younger disabled adults and people with mental health conditions. The service also provides care and support to people living in three ‘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. At the time of our inspection 22 people were receiving personal care from the service.

There were two registered managers in place. One registered manager was responsible for the domiciliary care agency part of the service and the other registered manager for the ‘supported living’ part. 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.

Risks to people using the service were assessed and plans put in place to reduce the chances of them occurring. Accidents and incidents were monitored to see if lessons could be learned to improve people’s safety. Medicines were managed safely. People were safeguarded from abuse. People were usually supported by stable staffing teams and support workers they knew. The provider’s recruitment processes minimised the risk of unsuitable staff being employed. Policies and procedures were in place to promote infection control.

Staff completed a wide range of mandatory training and were supported with regular supervisions and appraisals. People were supported to have 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. People received support with managing food and nutrition and to access external professionals to monitor and promote their health.

People described staff as kind and caring and spoke positively about the support they provided. Relatives also spoke positively about the support staff provided. People and their relatives said staff treated people with dignity and respect. People’s independence was promoted. Policies and procedures were in place to support people to access advocacy services where needed.

Care was based on people’s personalised needs and preferences. Policies and procedures were in place to investigate, respond to and learn from complaints. People were supported to access end of life care where needed.

Staff spoke positively about the culture and values of the service and most said it was well-led. People and their relatives knew the names of the registered managers and said they were approachable and easy to contact. The provider and registered managers carried out a number of quality assurance audits to monitor and improve standards at the service. Feedback was sought from people and staff. The registered managers had informed CQC of significant events in a timely way by submitting the required notifications.

This inspection took place on 7 December 2015 and was announced. The provider was given 48 hours’ notice because the location provides a domiciliary care services and we needed to be sure that the manager would be in.

Creative Support Middlesbrough and Stockton Services has its registered office at Innovation Court, Stockton-on-Tees. The service delivers support and/or personal care in eleven supported living services in the Middlesbrough and Stockton areas. Each of the supported living services provides support to people who live their own houses or flats, with their own tenancy agreements. The people using these services receive individual or shared support hours depending on their assessed needs and the service they are receiving. Some of the supported living services provide support on a twenty-four hour basis. 15 people were using the service at the time of the inspection.

The service did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. Creative Support are planning on separating Middlesbrough and Stockton services and had appointed a manager for each one. The managers were in the process of becoming registered with CQC.

Staff were trained in how to protect people from abuse and harm. They knew how to recognise signs of abuse and how to use the whistleblowing procedure. Risk assessments were centred on the needs of the individual. Potential risks to people had been identified and plans put into place to enable them to live as safely and independently as possible.

Robust recruitment checks took place in order to establish that staff were safe to work with people before they commenced employment. At the time of inspection they were trying to recruit new members of staff. Current staff were covering for the shortfall of staff over each service, which enabled staffing levels to be sufficient, whilst waiting for new staff members to start.

Medicines were stored, administered and recorded safely and correctly. Staff were trained in the safe administration of medicines and maintained relevant records that were accurate. We recommend that the service consider the current guidance on managing medicines that need to be administered ‘when required’’ and take action to update their practice accordingly.

Although staff received regular training which provided them with the knowledge and skills to meet people’s needs in a person centred manner, Mental Capacity Act and Deprivation of Liberty Safeguarding training had not taken place. They were well supported by the manager and senior management team in respect of supervision and informal support. Specialist training was provided to staff and the people who used the service’s families, that was specific to the person they were providing care for. This provided staff with the knowledge and skills to meet people’s needs in an effective and individualised way.

The manager and staff were aware of the requirements of the Mental Capacity Act 2005. Although staff had not received official training in MCA and DoLS they provided good explanations of their understanding. Mental capacity was assessed by either the social worker or healthcare professionals and this information was shared with the registered provider who used them to develop care plans for people. Where people lacked capacity, decisions were taken in their best interests. Care plans included instructions on how they should be supported and included their needs, likes and dislikes

People could access suitable amounts of nutritious food that they enjoyed and which met their individual preferences and dietary needs. Referrals to other health and social care professionals were made when appropriate to maintain people’s health and well-being. Staff worked closely with other professionals to ensure people’s needs were fully met.

There were positive relationships between people, their families and members of staff. People and their families were treated with kindness and compassion. People’s rights in making decisions and suggestions in relation to their support and care were valued and acted on. The privacy and dignity of people was promoted by staff and they treated people with respect.

People received care that was responsive to their needs and centred on them as individuals. People’s needs were assessed and care plans gave very clear guidance on how they were to be supported. Records showed that people and their relatives were involved in the assessment process and review of their care.

People were supported to access activities of their choice.

The service had an effective complaints procedure in place. There were appropriate systems in place for responding to complaints.

The director and manager regularly checked the quality of the service provided to make sure people were happy with the service they received.

The service provides support to over 100 people across the Teesside area and most need psycho-social support rather than personal care. The people who receive a personal care service live in shared houses or houses within a complex, which they rent from different landlords. Some of these people lack capacity and their tenancies have been agreed via the Mental Capacity Act use of Court of Protection procedures. We visited people in four of these houses and met twelve people during the inspection. As this was a routine visit we asked people about the service; what the care was like; and what people thought about the staff. People told us that they found the staff delivered an excellent service and they had no complaints.

People said ‘‘The staff are very good, I do lots for myself but they are good at helping me get out and about as well as cooking’’, ‘’I like the staff’’, ‘’I’m the boss and keep the staff in order’’, and ‘’I tell the staff what to do’’. A number of the people had limited verbal communication skills and from our observation of staff interactions with people we found the staff clearly understood what people we saying. Also staff constantly sought people’s views and permission around all aspects of the service they were delivering. People were very much in control of the service and staff understood exactly how much support each individual needed. Constantly we saw staff across the four houses encouraging people to be as independent as possible.

A single inspector carried out this inspection. The focus of the inspection was to look at the chosen regulations and use what we found to answer five key questions; is the service safe, effective, caring, responsive and well-led?

During this inspection we visited the service's registered office, where we spoke with the registered manager and service director, and looked at records. We also visited two of the supported living schemes where personal care was being provided. We spent time meeting and speaking with eight people who used the service. We also spoke with six staff and we looked at records. Some of the people who used the service had complex communication needs, making it difficult for us to speak with them about their care and support. To help us better understand people’s experiences we spent time in the supported living services, so that we could observe how people were supported by staff.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

Creative support had in place arrangements to assess and plan people’s care and support needs. This included risk assessments and arrangements to manage behaviour that challenges in a safe and consistent way. For example, staff who worked in services where people experienced behaviour that challenges had received appropriate training and people had detailed personal behaviour support plans in place. This helped to ensure that staff responded in safe, consistent ways, which were safe and effective for the individuals involved. The service had in place systems for the safe management and administration of medication.

Staff told us that they received training, with access to regular training refreshers and updates. The training records we were provided with showed that staff had completed a variety of training relevant to their roles. However, training records did not always demonstrate that staff had completed all of the training listed on the services ‘Mandatory Training Matrix’ or the training update frequencies suggested by the services training calendar.

We found that the services quality assurance systems included checks and audits related to health and safety. For example, regular checks of the arrangements for fire safety and maintenance in the supported living services.

Is the service effective?

People who used the service told us that they were happy with their care and support. During our visits we saw that people looked well cared for and appeared comfortable and at ease with the staff in their homes. Records showed that people’s care and support needs had been assessed, planned and reviewed. Staff knew people well. For example, staff could explain how different people communicated, how people liked to be supported and how they involved people in discussions about their care service.

Is the service caring?

People we spoke with told us that they got on with their staff and that staff treated them well. We observed staff treating people who used the service with respect. People appeared comfortable with their staff, conversing and interacting with them in a friendly and relaxed way. The staff we spoke with knew the people they supported well and could explain their individual preferences and how they liked to be supported.

Is the service responsive?

People’s needs had been assessed and planned. Reviews took place regularly and included people who used the service, relatives and other professionals where appropriate. Records showed that people were also asked for their views and involved in discussions about their service during tenant’s meetings.

Is the service well-led?

The service had a registered manager who had management oversight over the services included in this registration. However, the registered manager was also responsible for two other registered services, but did not have management oversight of those services. Creative Support had recently recruited a new regional service director and was in the process of reviewing the management structure, which included looking at the arrangements for registered managers and making the management structure more effective.

Quality assurance (QA) systems were in place, including arrangements for staff supervision and support, local maintenance checks and audits at both local and corporate level. However, we highlighted some inconsistencies in quality assurance systems across different Creative Support registered services and individual services. We saw that good practice in one area had not been recognised and implemented in others and found some variations in quality. For example, the implementation of medication checks and corporate staff supervision and support systems varied across different individual services. We discussed this with the service director who was already aware of these inconsistencies and was looking at how QA processes could be improved and strengthened across the organisation.

What people told us about the service:

The people who used the service told us they were happy with the support they received and were involved in their service. Comments made to us included “They talk to me, treat me with respect”, “We’re having a tenant’s meeting tomorrow and can bring up anything that is worrying you or you want to talk about”, “My support is fine, spot on”, “I’m very happy with the package I get”, “Staff have always been polite and kind” and “You can talk to them and they are nice to you.”

Staff felt that the service was tailored to people’s individual needs, with staff comments including “I do genuinely think this is the best place I’ve worked for person centred care” and “Their individual support depends on people’s wishes and abilities.” Staff also told us that they were supported and provided with the training they needed to do their jobs. Staff comments included “I’ve never felt alone or as if I don’t have support, it’s always been there”, “There are plenty of training opportunities” and “One of the best bosses I’ve ever had, very supportive, approachable, listens.”