This inspection took place on 23 January 2018; the inspection was unannounced.

At our previous inspection in November 2016, we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 for Regulations 12, 17 and 19 relating to how risks were managed, governance and staff recruitment. We asked the provider to complete an action plan to show what they would do and by when to improve the rating to at least ‘good’. At this inspection we found improvements had been made and the service was no longer in breach.

Lyncroft is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Lyncroft accommodates up to nine people in one adapted building. At the time of our inspection nine people lived at Lyncroft.

The service is required to have a 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. At the time of our inspection there was a registered manager in post and was present at the inspection.

Enough staff were available to meet people’s needs as well as spend time with people on an individual basis. Staff had been trained in safeguarding and understood how to raise any concerns. Recruitment processes were in place to ensure any new staff would be subject to pre-employment checks on whether they were suitable to work at the service.

People managed their own medicines when appropriate. Arrangements for medicines management followed procedures designed to ensure safe medicines practice.

Processes were in place to ensure risks and people’s health needs were assessed, managed, monitored and responded to. The premises had been adapted in ways to make sure it was suitable for people using the service.

People’s needs and choices were promoted in a way that prevented and reduced the impact of any discrimination. People’s communication needs were assessed and people were supported to communicate effectively with staff. The Accessible Information Standard was being met. The principles of the MCA were followed.

Staff were trained and supported. Staff were caring and showed consideration to how people may feel; staff took steps to understand and know people well. People’s privacy was respected and people were supported to be active in their local communities. People were supported to be independent and were actively involved in decisions about their care. People enjoyed a variety of different interests and hobbies and looked forward to the plans they had made for future events and holidays.

People felt able to raise any issues or concerns; there was a complaints process in place to manage and respond to any complaints should they be made.

The registered manager focussed on providing care that was centred on individuals; they promoted an open and transparent management style. The registered manager had audits and checks in place to provide assurances for the governance of the service. Policies and procedures had been updated to reflect the needs of the service.

This inspection took place on 15 November 2016 and was unannounced.

There is a requirement for Lyncroft to have a registered manager and a registered manager was in place. 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 service is registered to provide residential care for up to nine people who have a learning disability or who are on the autistic spectrum. At the time of our inspection eight people were using the service.

Risks to people’s health and safety, including risks if there was a fire, were not consistently identified. In addition, risks to people’s health conditions and actions to reduce those risks were not always identified in care plans and risk assessments. Guidelines to ensure the safe management of medicines were not always followed. Medicines were not always disposed of when they were out of date and the effectiveness of medicines could not be confirmed as no record had been made of how long they had been open for. Other medicines were seen to be managed and administered safely.

Staff recruitment practices did not record all checks on people’s suitability to work at the service had been completed prior to them starting work. This included records to confirm staff had a satisfactory criminal records check in place before starting work. In addition, not all staff had been asked about their health prior to starting their employment nor had people’s employment history been checked to ensure any gaps had a satisfactory explanation.

Systems were not effective at identifying shortfalls in the quality and safety of services provided. Audits were not comprehensive and did not identify how compliance was measured. Policies and procedures did not ensure the services provided met with the requirements of the current Health and Social Care Act 2008. Records for the management of the service were not always well organised.

The registered manager had not fully applied the principles of the Mental Capacity Act (MCA) 2005 to people’s care, support and decision making. Staff checked people consented to their day to day care and support, however not all staff had a full understanding of the MCA and DoLS and how it applied to people’s care.

Staff had training on how to safeguard people and people and families told us they felt cared for safely.

People made choices from healthy, nutritious food and drink menus. People received effective care for any health conditions and had access to specialist health professionals when required.

Staff were thoughtful and caring, and supported people to maintain their dignity and independence. People were supported to develop their confidence. People’s views were sought and respected and they were involved in planning their own care.

People received personalised and responsive care as staff understood their needs and preferences. People contributed to their care planning and were asked for their views at regular meetings and by completing questionnaires.

The registered manager was supported by a enthusiastic and caring staff team. Staff were motivated and understood their roles and responsibilities.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the end of the full report.