This inspection was unannounced and took place on 10 July 2018. Flat C, 291 Harrow Road is a ‘care home’ providing support to people with learning disabilities. 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. Flat C consists of five separate bedrooms, a communal lounge/dining area and kitchen and an outside seating area/courtyard. There were five people living at the service at the time of our visit.

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 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.

At our previous inspection of Flat C, 291 Harrow Road in October 2017, we rated the service as 'Requires improvement' overall. You can read the report from our previous inspections, by selecting the 'all reports' link for Flat C, 291 Harrow Road on our website at www.cqc.org.uk.

At this inspection, improvements had been sustained and we found evidence that supported the rating of ‘Good’ overall.

The service had a registered manager in post who was supported by a deputy manager. She was visible within the service and spent time engaging with people using the service, staff members and visiting healthcare professionals.

Individual care and support plans had been developed for each person using the service and contained a good level of detail around people's individual needs, life histories and personal preferences.

People were protected from avoidable harm because any potential risks to people and/or others had been identified and management guidelines were in place to ensure people were supported in a safe and appropriate manner. Staff knew people well and were aware of the risks to individuals and how these could be managed.

The provider was operating effective procedures to ensure the safe storage, management and administration of medicines. Staff completed appropriate medicines training and competency assessments before carrying out medicines related tasks and were confident supporting people with their medicines.

Staff references were taken up and verified before staff started work, and the provider obtained sufficient proof of identification and carried out Disclosure and Barring (DBS) checks. The DBS provides information on people's background, including convictions, in order to help providers make safer recruitment decisions. There were enough staff deployed to support people with their needs.

Records showed that staff had up to date training in essential areas such as moving and positioning, safeguarding adults, first aid, mental health legislation, fire safety and food safety and hygiene. Some staff members had completed specialist training in diabetes and epilepsy. People were supported by staff whose performance was appraised on an annual basis. Supervision sessions were delivered by the management team in line with the provider's policies and procedures.

People's health and well-being was being promoted. Systems in place ensured that people were seen by the appropriate healthcare professionals at the appropriate time. People were supported to attend annual health checks with their GPs. Where people had complex healthcare needs, staff sought relevant guidance from a range of healthcare professionals such a wheelchair specialist

We carried out an unannounced comprehensive inspection of this service on 28 and 29 March 2017 at which a breach of legal requirements was found. This was because people were not always being protected against the risks associated with the unsafe storage, management and administration of medicines.

After the comprehensive inspection, we asked the we asked the provider to write to us by July 2017 to say what they would do to meet legal requirements in relation to the breach. We did not receive an action plan despite our request.

We undertook a focused inspection on the 11 October to check that appropriate and safe systems and procedures were in place in relation to medicines.

This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘291 Harrow Road Flat C' on our website at www.cqc.org.uk’

291 Harrow Road Flat C, consists of five separate bedrooms, a communal lounge/dining area and a kitchen. The service is registered to provide support with personal care to people with learning disabilities. There were five people living in the flat at the time of our visit although one person was absent due to a hospital admission.

The manager had completed the application process to become the registered manager of the service. 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 and associated Regulations about how the service is run.

At our focused inspection on the 11 October 2017, we found that the provider had adequate systems in place in relation to the safe storage and administration of medicines and legal requirements had been met.

During this inspection, we found that medicines were stored safely. A GP had reviewed people's use of emergency medicines and following a clinical decision these were no longer being prescribed or used by people using the service. Medicines were stored in a cupboard that was kept locked when not in use. Controlled drugs were stored appropriately and all medicines were checked and counted in to the service when delivered.

Auditing systems were in use and we saw no discrepancies in medicine's quantities. Medicines administration records were signed appropriately when medicines were administered and we observed no omissions or errors in the completion of this task. Keys to the medicines cupboard were held by the shift leader and therefore easy to locate. This meant the provider was operating effective procedures to ensure the proper and safe management and storage of medicines.

This inspection was unannounced and took place on 28 and 29 March 2017. Flat C, 291 Harrow Road consists of five separate bedrooms, a communal lounge/dining area and a kitchen. The service is registered to provide support with personal care to people with learning disabilities. There were five people living in the flat at the time of our visit although one person was absent due to a hospital admission.

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 registered manager was well regarded by relatives and the wider staff team.

Relatives and health professionals were involved in planning people’s care. Care plans were split into person-centred plans, health assessments, health action plans and risk assessments. However, staff were not always aware of specific details relating to people’s health conditions, care needs and preferences and as a result people's human rights were not always being protected in accordance with the requirements of the Deprivation of Liberty Safeguards (DoLS).

Staff were trained in the safe administration of medicines and kept relevant and accurate records. However, people's medicines were not always being stored safely and securely.

People’s risk assessments covered a range of issues including guidance around accessing the community, personal care, moving and positioning and safety within the home environment. However, risk assessments were not always being reviewed when people’s health status changed or when new circumstances created potential risks to people’s health and well-being.

There were sufficient numbers of staff deployed to the service. Recruitment procedures ensured that only staff who were suitable worked within the service. Staff files contained appropriate references and identity checks with the Disclosure and Barring Service.

New staff completed an induction programme which included shadowing more experience staff and completing elements of the care certificate which prepared them for their role and duties. Staff were given opportunities to develop professionally through regular training opportunities and ongoing supervision sessions. Staff told us they felt supported by the management team.

Staff received training in safeguarding adults and understood the procedures to follow should they have any concerns. The registered manager ensured that action was taken after incidents and accidents occurred.

People were cared for by motivated staff and positive relationships had been established between people using the service and staff. Staff interacted with people in a kind and caring manner and respected people's privacy and dignity.

There were activities in place which people enjoyed. However, one person was not able to access the community due to a faulty wheelchair and repair delays.

People had sufficient amounts to eat and drink and were offered choices at mealtimes. Staff were aware of people’s specific needs in relation to specialist diets and food preparation and had completed safe food handling training.

There was a complaints procedure in place and the provider listened to the views of staff, relatives and visitors. The manager understood the requirements of CQC and sent in appropriate notifications. Relatives told us they felt that the management was approachable and responsive.

There were procedures in place to monitor, evaluate and improve the quality of care provided though these systems were not always effectively identifying and addressing the shortfalls we found during our inspection.

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service and their relatives/friends told us, the records we looked at and what staff we spoke with also told us.

If you would like to see the evidence that supports our summary then please read the full report.

Is the service safe?

We looked at two care records and saw that these contained a variety of risk assessments which included those in relation to the environment, personal care and fire safety.

The service had a safeguarding policy and procedure in place. All staff we spoke with were aware of their responsibilities to report any concerns they had about potential safeguarding issues and were able to describe potential signs of abuse.

Appropriate checks were undertaken before staff began work. All staff were required to undergo a Disclosure and Barring Service check (previously a Criminal Records Bureau check) before commencing employment.

There were arrangements in place to deal with foreseeable emergencies. All staff had received first aid training which was repeated annually. There was a policy in place for dealing with accidents and incidents and we were told that a senior staff member was always on call in case of an emergency. We spoke with three members of staff and each person correctly explained the policy for handling an accident or incident.

Is the service effective?

Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. We spoke with three members of staff about how they obtained consent from people using the service on a daily basis. We were given detailed examples of the routines of each person as well as the general likes and dislikes of people.

CQC monitors the operation of the Deprivation of Liberty safeguards (DoLS) which applies to care homes. Staff were aware of the policies and procedures relating to the Mental Capacity Act 2005 (MCA 2005) and DoLS and understood when an application should be made and how to submit one. No applications had been submitted at the time of our visit.

Is the service caring?

One of the people who used the service told us that "the staff are really nice." We carried out observations using the Short Observational Framework for Inspection (SOFI) and observed positive interactions between staff and people using the service.

There were a range of activities available for people who used the service. This included an art group, going out to the park and pampering sessions for example massage.

Is the service responsive?

Staff told us that they organised resident’s meetings where issues such as the range of activities, food choices, the home environment, staffing and well-being were addressed.

Is the service well-led?

The service had a registered manager in post. Staff we spoke with told us that the manager operated an open door policy.

Staff meetings took place every month and a separate residents meeting took place once a month. We saw that an annual audit took place every year and monthly compliance audits were also conducted.

We used a number of different methods to help us understand the experiences of people using the service because they had complex needs which meant they were not able to tell us their experiences. We also observed the practices of staff when interacting with the people who live there. Staff interactions were well paced. We looked at the provider’s 2012- 2013 feedback survey. This was a survey of all its services, including those at 291 Harrow Road. People were satisfied with the care and treatment they had received and were happy living in their accommodation.

People were assessed regularly by staff to ensure that all their care needs were being met. This included assessing their nutritional status on a monthly basis.

All people's risk assessments and care plans were up to date.

The service had procedures in place to prevent abuse from happening and provided annual training to staff in safeguarding vulnerable adults.

People were cared for in a clean, hygienic environment by staff that had been trained, supervised and supported to undertake their duties appropriately. Staff had received training in infection control and there was a policy and procedure in place.

People were cared for in safe, accessible surroundings which promoted peoples’ wellbeing. However, some areas of the home were in need of repainting.

There was a complaints policy in place and people were given information on how to make a complaint.

We used a number of different methods to help us understand the experiences of people using the service because they had complex needs which meant they were not able to tell us their experiences. We spoke to a visiting relative and with staff that worked in the service. We also observed the practices of staff when interacting with the people who live there. These observations told us that staff treated people with respect and dignity. We saw that there was a rapport that was positive, supportive and sociable. A visiting relative described staff as “brilliant.” They said that they knew their relative was happy living in the service and they felt they were “safe and very well cared for”.

We found that the service was not consistently monitoring a person's care and staff could not always locate records that we asked to see as part of our inspection.

Due to differing levels of communication skills we focused on care practice observation rather than gaining direct views of people who use the service. This told us that staff treated people who use the service with respect and dignity. They were enabled and encouraged to make their own decisions and choices, including care, treatment and joining in with activities provided. People were living in a safe environment where they were well protected. The meal we saw was good, plentiful and the choices available were appropriate from a cultural and religious perspective.

Staff were friendly, supportive, knew their jobs and there were enough of them to meet people's needs.

People were supported to make complaints as required.

This inspection took place on 28, 29 May and 1 June 2015. The visit was announced. Flat C, 291 Harrow Road consists of five separate bedrooms, a communal lounge and a kitchen area. The service provides accommodation for people with learning disabilities. There were five people living in the flat at the time of our visit.

During this visit we identified shortfalls in the provision of care and support in relation to medicines management. We observed low levels of interaction and engagement between staff and people using the service and feedback from relatives indicated that contact between staff and family members was inconsistent.

The service had a manager in post who was in the process of registering 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 received referrals from social workers based in Westminster. Initial assessments were carried out by senior staff members to ensure that the service was able to identify and meet people’s support needs before they moved into the service on a permanent basis.

Care plans were developed in consultation with people and their family members. Where people were unable to contribute to the care planning process, staff worked with people’s representatives and sought the advice of health and social care professionals to assess the care needed.

People’s risk assessments were completed and these covered a range of issues including guidance around accessing the community and personal safety.

The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and DoLS, and to report upon our findings. DoLS are in place to protect people where they do not have the capacity to make decisions and where it is regarded as necessary to restrict their freedom in some way, to protect themselves or others.

Staff had received training in mental health legislation which had covered aspects of the MCA and DoLS. Senior staff understood when a DoLS application should be made and how to submit one.

Staff were familiar with the provider’s safeguarding policies and procedures and able to describe the actions they would take to keep people safe.

Staff supported people to attend health appointments and had received training in first aid awareness. There were protocols in place to respond to any medical emergencies or significant changes in a person’s well-being. These included contacting people’s GPs, social workers and family members for additional advice and assistance.

People’s independence was promoted and staff actively encouraged people to participate in activities. People were supported to attend museums and musical performances. People were also able to take trips out and go away on holidays.

Staff were aware of people’s specific dietary needs and preferences and offered people choices at mealtimes. Where people were not able to communicate their likes and/or dislikes, staff sought advice and guidance from appropriate healthcare professionals and family members.

There were arrangements in place to assess and monitor the quality and effectiveness of the service. This included house meetings, family meetings, telephone reviews and medicines administration auditing. Most family members expressed positive views about the service, the manager and the staff.