The inspection took place on 23 and 25 July 2018.

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 service.

The service provides personal care for older people and younger adults. This was the first inspection of the service. It was a comprehensive inspection. The registered manager stated that 20 people were receiving a personal care service at the time of the inspection.

The inspection was announced because we wanted to make sure that the registered manager was available to conduct the inspection.

A registered manager was in post. This is a condition of the registration 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.

We identified concerns about a number of issues. A requirement notice has been issued due a breach of regulation in relation to the service not comprehensively meeting requirements of safe care and treatment.

Staffing was not always in place to always provide people with the safe personal care they needed. Risk assessments were not always comprehensively in place to protect people from risks to their health and welfare. Lessons had not always been learned from complaints.

Calls to people had not always been timely and some calls had been less than the agreed times.

People and relatives said that concerns had been followed up. However, a written response was not always provided to the complainant to indicate how their complaint had been investigated and action taken if needed.

Most staff members said they had not been fully supported in their work by the registered manager.

Management had not carried out comprehensive audits in order to check that the service was meeting people's needs and to ensure people were provided with a quality service.

Policies set out that when a safeguarding incident occurred management needed to take appropriate action by referring to the relevant safeguarding agency. Incidents have been reported to us, as legally required.

Staff understood their responsibilities under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) to allow, as much as possible, people to have effective choices about how they lived their lives. A capacity assessment was in place to assess whether any restrictions on choice were needed in the person’s best interests. Staff had asked people’s consent when they provided personal care.

Staff had largely received training to ensure they had skills and knowledge to meet people's needs, though training on some other relevant issues had not yet been provided.

People and relatives told us that staff were friendly, kind, positive and caring, when providing personal care. People had been involved in making decisions about how and what personal care was needed to meet their identified needs.

Care plans contained detailed information individual to the people using the service, to ensure that their needs were met. Staff had not read all the care plans for people, which meant a risk that people’s individual care needs may not be fully met.

Staff recruitment checks were in place to protect people from receiving personal care from unsuitable staff.

Most people and their relatives told us that they thought staff provided safe personal care.

Staff had been trained in safeguarding (protecting people from abuse) and understood their responsibilities in