We undertook an unannounced focused inspection of Housing & Care 21 - Cedar Court on 19 and 20 July 2018. This inspection was done due to concerns we had received about the service. We inspected the service against two of the five questions we ask about services: is the service safe and; is the service well led. This is because of concerns that 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.

Housing 21 Cedar Court provides personal care and support for up to 40 people aged 55 and over. At the time of inspection, 37 people were using the service and one person was in hospital. This service provides care and support to people living in specialist ‘extra care’ housing. Extra care housing is purpose-built or adapted single household accommodation in a shared site or building. The accommodation is rented, and is the occupant’s own home. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for extra care housing; this inspection looked at people’s personal care and support service.

Accommodation is located over three floors, which is wheelchair accessible with lift access to all floors. There are communal areas, solely for the use of people living at Cedar Court, including a living room and quiet room on the first floor. Care staff are available on-site 24-hours a day.

At this inspection, we found that people had not always received safe and appropriate care. Staffing levels were not sufficient to meet people’s needs. Risk assessments and management plans were in place. However, these were not always reviewed and updated in a timely manner to ensure staff provided care in a safe manner. Staff did not support a person to transfer safely from a chair to a wheelchair.

There was no registered manager. The previous manager left the service in May 2018. A manager had been appointed and would be applying for registration with the Care Quality Commission. 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 received the support they required to take their medicines. Medicine errors were identified and resolved.

Staff understood the safeguarding procedures to follow to identify and report abuse. Accidents and incidents were reported and action taken to minimise the risk of a recurrence. People received care from staff deemed suitable to provide support. Staff followed good infection control and prevention practices.

Staff morale and teamwork varied amongst team members. The provider had restructured the service and had put plans in place to support staff. Staff had started to see the benefits of the management’s intervention in building a cohesive staff team. However, it was too early to see how consistent and embedded the new culture will be. Some staff felt unable to approach the managers and highlighted some disharmony within the team. Some staff felt unsupported in their roles and were not confident their concerns were taken seriously. People using the service did not feel comfortable naming staff where there were concerns.

The provider worked with other agencies to deliver high standards of care. Audits were carried out on the quality of the service. Improvements were carried out although some shortfalls were not always identified and/or acted on.

We found two breaches of regulation relating to safe care and treatment and staffing. You can see what

This inspection took place on 13 and 14 December 2016 and was announced. We gave the registered manager 24 hours’ notice as we needed to be sure they would be available for the inspection.

When we last visited the service on 23 May 2014, the service was meeting all the regulations we checked.

Housing and Care 21 – Cedar Court is extra care sheltered housing for older people. Personal care is provided to people who require it. At the time of the inspection 35 people were using the personal care service provided by Housing and Care 21 – Cedar Court.

The manager in post was new and had not yet registered with CQC as the registered manager. 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.

Medicines were handled and administered safely. Staff understood the organisation’s medicines policy and followed it to ensure people received their medicines safely. Medicine administration records were completed accurately.

Risk assessments were in place and detailed actions to manage identified risks and to keep people safe. These covered risks associated with people's care, their environment and their health conditions.

Recruitment procedures were robust and safe. Only members who had successfully completed all checks including references and disclosure barring checks were allowed to work at the service. Staff understood how to recognise signs of abuse and how to protect people from the risk of abuse. Records showed that safeguarding concerns were taken seriously and investigated.

Staff understood their responsibilities within the Mental Capacity Act 2005. Staff were supported through effective induction, supervision, appraisal and training to provide an effective service to people. Staff were supported and supervised through one-to-one meetings, spot checks and observation. They told us it helped improved their performance.

The service worked with social care and health care professionals. People were supported to arrange appointments to ensure their health needs were met. Relevant professionals were involved to ensure people received appropriate support and care that met their needs. People were supported to eat and drink appropriately and to meet their dietary and nutritional requirements.

People told us staff treated them with kindness, compassion and respect. Staff provided support to people in the way they wanted to be cared for. People and their representatives were involved in their care planning and these were reviewed and updated regularly to reflect people’s changing needs.

People, their relatives and staff were encouraged to provide feedback and to raise concerns. The registered manager investigated and responded to complaints and concerns appropriately to improve the service. The service had various and effective systems to monitor the quality of service delivered. They worked in partnership with other agencies to deliver effective service to people.

This inspection was carried out by an inspector who gathered evidence to answer our five questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, and staff supporting them and from looking at records. We spoke to five people using the service out of 34, five relatives and five staff.

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

Is the service safe?

Staff were trained in their roles to support people safely. There was a safeguarding policy in place and staff understood the types of abuse and how to report it. Risks were assessed for people and actions were taken to address any risk promptly. Staffing levels were adequate and they were trained and competent in their roles. There was a plan for how to respond to unforeseeable emergencies. Medication was handled safely. The service was covered by care staff 24 hours a day and people told us they felt safe living at the service. Incidents and accidents were recorded and reviewed and lessons learned were discussed with staff. Equipment was assessed and provided for people who had mobility problems and staff had received training in using these.

Is the service effective?

People’s care was planned and delivered in a person centred way. People were involved in their care planning. The provider involved other healthcare professionals in the planning and coordination of people’s care and treatment. We saw evidence of the involvement of a speech and language therapist (SALT) in supporting one person with swallowing difficulties and recommendations were implemented by staff. Staff responded to alarm calls promptly and flexibly to meet the needs of people. People were supported to access activities taking place at the service.

Is the service caring?

Staff understood the needs of people they supported. People using the service told us that they were treated with dignity and respect. One person said, “Staff are nice and they look after me well.” Another said “The staff are good. They do a good job.” We observed staff interacted and responded to people in an open and positive manner. People’s care plans detailed their likes and dislikes and care delivery centred on what people needed, and reflected their preferences, interests, and choices.

Is the service responsive?

People’s choices and independence were promoted by staff in the way they were supported. One person told us “I’m encouraged to do as much as I can for myself.” We saw staff attending to calls from people and responding to alarm bells. There were activities within the service which people participated in. The provider liaised effectively with other health and social care professionals to ensure the service responded to people’s needs. Care plans were reviewed and updated to reflect changes in their needs and circumstances. Additional care support was implemented if required.

Is the service well-led?

The provider worked well with other agencies in meeting the needs of people using the service. There were quality assurance systems in place to identify, assess and monitor the quality of service provided. We saw records of complaints and actions taken to address them. People using the service and their relatives told us that management take complaints and comments seriously and sort things out quickly.

We spoke with five people who were using the service. Four of the people were satisfied with the care that they received. One person said "They are quite friendly. They look after me." Another person told us "I like it here. I like the carers. They are nice to me." However, one person told us "I tell them what I want, but they don't do it."

We saw that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The provider also had an effective system to assess and monitor the quality of service that people received. They regularly received feedback from staff and people using the service through the use of meetings and surveys.

There was some evidence that people were not being protected against the risks associated with the use of medicines. This was because records of the use and disposal of medicines were not kept accurately. This meant that there was some moderate risk to the people using the service because it was not possible to tell if people had taken the correct amount of medicine.

We also found that the provider was not able to respond to unexpected changes in the service, such as sickness cover or other staff absence. This had a moderate impact on the safety and welfare of the people using the service because their care needs were not always met in a timely manner.

At our previous inspection on 20 November 2012 we found that people were not always protected from the risk of infection. We also found that care staff shortages had an impact on staff, who told us they were finding it difficult to cover all their required tasks, which meant there was a risk that people using the service may not have had access to sufficient numbers of suitably qualified, skilled and experienced staff at all times.

At our visit on 5 February 2013, we saw that the provider had taken steps to ensure that there were effective systems in place to reduce the risk and spread of infection and that infection control training had been attended by most staff.

There were enough qualified, skilled and experienced staff to meet people’s needs at all times, and staff were being supported, through training and supervision, to deliver care and treatment safely and to an appropriate standard.

During our visit we observed good, friendly and professional communications taking place between staff and service users. One person told us “if I want anything I just ask and I get it.”

People understood the care and treatment choices available to them. Copies of care and support plans were available in people's flats, and they told us that their keyworkers had discussed the plans with them and that their views were taken into account by their carers.

Staff at Cedar Court met peoples’ individual health and care needs well. People we spoke with told us that they had rarely had to raise any issues, but that if they did, staff responded quickly and tried to find solutions to address the problem.

People felt that their privacy and dignity and independence were respected. One person told us “I’ve got my own flat, I can come and go as I want but with back-up. I want my independence.”

However, there had been staff shortages and while these had not significantly impacted on the core tasks or care given to people, staff told us they were finding it difficult to cover all their required tasks. The provider had responded by recruiting a number of new staff, but they had not yet started working at Cedar Court.

Additionally, although communal areas and flats at Cedar Court were visually clean, we found that infection control training had not been made available for all staff and not all staff were following appropriate infection control practices.

People we spoke with who used the service said they had been asked by the agency about the support they needed. They said they knew there was a care plan for them, and they were happy we examined it as part of the inspection. They said they were able to ask staff when they needed help or advice and staff listened to them. They said the staff would do extra jobs if they asked them to.

People who used the service told us the same staff usually supported them and said that they knew their care needs well. They said the staff were respectful and friendly, and they felt they were in safe hands when being supported. All of the people we spoke with who received a service said they knew the manager and that she visited them in their home regularly and worked with the staff sometimes to observe the quality of their work, and give advice and support..

People who received support said they felt staff supported them in the way they wanted, and were caring and helpful. All were aware of their care plan, and they told us a copy of which was in their home.

Overall people told us that they were happy with the care they received and that the staff were friendly and helpful.