We carried out this unannounced inspection on 12 and 13 September 2018. This was the first inspection since the provider registered this location in March 2018.

‘London Care (Lime Tree House)’ is an extra care service, which provides care and support to people who live in their own homes. 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. The Care Quality Commission (CQC) does not regulate premises used for extra care housing; this inspection looked at people’s personal care and support services.

At the time of our inspection the service was providing care to 34 people who lived on site. The provider also manages the Night Owl service from this location. This service supports people who live in their own homes and require personal care during the night. There were 16 people using the Night Owl service.

The service had a registered manager. A registered manager is a person who has registered with 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. The provider had taken over the management of the service from another provider in February 2018. We found that several aspects of the transition process were badly managed.

The provider told us that the previous care provider had taken all risk assessments and care plans which were required to run the service. Since taking over the Night Owl service the provider had failed to complete assessments, care plans and risk assessments for all but two people. Care workers were relying on information provided by the local authority, but had not checked whether this information was in date. At times people’s timings and care needs had changed but this was not reflected in a care plan. At times people had needs relating to skin integrity or being supported to walk but the provider had not carried out risk assessments about these tasks, and so lacked a risk management plan. As there were no care plans to consent to, the provider had not obtained consent to care or checked whether people had the capacity to do so. This situation had arisen because there was not a clear line of management responsibility for the Night Owl service, and a single dedicated manager had only been allocated the week before our inspection.

At our request, the provider carried out these assessments after the inspection and provided evidence that they had done so.

There was no system in place to monitor, log and investigate incidents. Medicines were not safely managed as systems of audit had been devised but had not yet been implemented. This meant that where there were gaps in the recording of medicines these were not always followed up. Risk management plans for medicines were not always consistent about the level of support people required, and lacked detail on what medicines people took and the risks associated with these.

The staff team and manager had transferred to the new provider. As part of this the provider had checked that staff were suitable for their roles by carrying out appropriate pre-employment checks. There were systems in place to check care workers had the right skills to carry out their roles such as training and assessments of staff knowledge and competency. Within the extra care service there were plans in place to assess and manage risks to people who used the service.

We found breaches of regulations relating to safe care and treatment and the management of medicines, good governance, consent to care and person-centred care. You can see what action we told the provider to take at the back of the full version of this report.