This announced comprehensive inspection took place on 8 January 2018.

At the previous inspection we found breaches of regulation in relation to; the need for consent and good governance. As part of this inspection we checked to see if the necessary improvements had been made and sustained.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions; Effective, Responsive and Well-led to at least good. We found that improvements had been made in accordance with the action plan in each of the key questions. The service was now meeting regulatory requirements.

This service provides care and support to people living in two ‘supported living’ settings, so that they can live in their own home as independently as possible. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people’s personal care and support.

A registered manager was 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 the last inspection in November 2016 we identified a breach of regulation 11 (Need for consent) because there were no suitable arrangements in place for obtaining consent and acting in accordance with the Mental Capacity Act (2005). As part of this inspection we checked records to ensure that improvements had been made and sustained in accordance with the provider’s action plan.

The records that we saw indicated that the service operated in accordance with the principles of the MCA. It was clear from care records and discussions with people that consent was sought and recorded in relation to care and treatment. People’s capacity to consent to care was assessed and recorded.

The provider was no longer in breach of regulation 11 regarding the need for consent.

At the last inspection in November 2016 we identified a breach or regulation 17 (Good governance) because the provider had failed to maintain an accurate and contemporaneous record in respect of each person receiving a service. As part of this inspection we checked records to ensure that improvements had been made and sustained in accordance with the provider’s action plan.

The care records that were held within the person’s own home contained the same information as those in the registered office and were supplemented with daily notes. The daily notes were respectfully worded and provided staff with important information about; health, activities, sleep-patterns etc.

It was clear from the records that we saw that improvements had been made and sustained in accordance with the provider’s action plan.

The provider was no longer in breach of regulation 17 regarding good governance.

People spoke positively about the safety of the service provided. We saw that the service had well-developed and extensive systems for protecting people from the risk of abuse or neglect. The staff that we spoke with were clear about their responsibilities in relation to safeguarding and said that they would not hesitate to report any concerns to their managers or externally (whistleblowing) if necessary.

The care records that we saw clearly demonstrated that risk was assessed and reviewed to keep people safe. It was equally clear that positive risk taking was encouraged to help people to develop their skills and independence.

The records that we saw provided evidence that staff were safely recruited and deployed in sufficient numbers to keep people safe. Each of the records contained a recent Disclosure and Barring Service (DBS) check, photographic identification and two references.

The service adhered to best-practice gui

This inspection visit took place at Natural Networks Individualised Support Service on 2 November 2016 and was announced. We told the service manager 24 hours’ before our visit that we would be coming. We did this to ensure we had access to the main office and the management team were available.

Natural Networks Individualised Support Service is registered to provide personal care to people living in their own homes. The service supports people who have a learning disability, mental health needs or an acquired brain injury. The service is located in Liverpool, Merseyside and it covers that geographical area and Wirral. The service is a domiciliary service and people using the service are provided with a range of hours per day or per week in line with their assessed needs. The service was providing support to nine people when we inspected.

There was no registered manager in place. However there was a new manager who had started the process to apply for registration with the Care Quality Commission (CQC). 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.

We talked with people where possible. Where people had limited communication and were not able to tell us verbally about their experience in the supported houses, we observed care and staff interactions or spoke with people’s relatives. People said staff were attentive, caring supportive and helpful and respected their privacy and dignity.

Staff were aware of how to support people and keep them safe. They were aware of how to raise concerns about poor practice or abuse should they need to. We saw staff received frequent and relevant training.

Staff recruitment was safe and robust so that risks of employing unsuitable people were reduced. Staff had to wait for all required checks before they could start working for the service. There were sufficient capable and experienced staff who provided a flexible service which met people’s needs.

Staff supported people to shop for and prepare nutritional and healthy food.

Staff supported people in a person centred way. Care plans were completed but not always in the person’s home or up to date, so staff did not always have written guidance on how people preferred to be supported.

People were given support and encouragement to develop new skills and interests, including work, social and leisure activities. They told us they were encouraged to make choices and decisions about their care and lifestyles. Relatives were also kept involved where appropriate.

People were supported to take any medicines . Medicines were managed carefully and given as prescribed. People said their health needs were met and staff responded to any requests for assistance promptly.

Staff were aware of the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS). However mental capacity was not always assessed or deprivation of liberty applied for via the court of protection. This meant that people were being deprived of their liberty without appropriate processes or records. Restrictive practice in place related to people’s external doors being locked. These were not supported by appropriate processes or records. The new manager had started to work on this so that staff would then work within the law to support people who may lack capacity to make their own decisions.

There was a transparent and open culture that encouraged people to express ideas or concerns. People and their relatives said their views and preferences were listened to and acted on.

People we spoke with told us they knew how to raise a concern or to make a complaint. One person told us, “I would tell my staff and they would make it right.” One relative spoken with said they had made a

We asked people using the service to tell us if they were making decisions about their care and support and people told us they were.

People told us that they were happy with the support they were receiving. People described staff as ‘good’ and they told us that staff listened to them and respected their wishes and choices.

We asked relatives to tell us if they thought people using the service were listened to, and if they as relatives were included in decision making. They told us they were.

People told us about a range of things they were doing with the support of staff. This indicated that staff were supporting people to make choices and to use their independent living skills.

We asked people if they felt confident to raise any concerns they had about the service and people told us they did. One person told us they had raised a concern in the past and this was dealt with to their satisfaction.

We asked relatives if they had any concerns or complaints about the service provided and they told us that they didn’t.

We asked people to tell us what they thought about the staff who were supporting them. People confirmed that staff were respectful towards them and that staff asked them what they wanted to do and listened to them.

People could tell us which members of staff were on their team and they told us that they had support from the same small group of staff.

Relatives told us there was a good level of consistency in the staff providing support. They told us that they felt staff knew the needs of the people they were supporting well. One relative told us that new staff shadowed more experienced staff before supporting people on their own.

One relative made some suggestions for how staff could interact more with one of the people using the service and this was received positively by the manager, who immediately came up with some suggestions to improve the service delivery for this person.

We spoke to four people who used the service who told us they were happy with the support they received. They described the staff positively and said that they listened to them and gave them the support they needed. They told us about a range of things they did with the support of staff which indicated that staff were supporting people to make choices and to use their independent living skills. Some comments made were:-

“I’m happy. The staff help me when I need it.”

“I am getting the support I need. The staff care about me.”

“The staff are nice. I get on with them.”

We spoke to five relatives, four told us they were happy with the service and that a good standard of care was provided. One relative raised some concerns about care practice which were brought to the attention of the manager to be addressed.

We found that records showed that the people who used the service had a support plan in place detailing the support they needed and how staff were to minimise risks to their well-being.

People’s nutritional needs were appropriately supported.

Staff were supported in their role and they were aware of the action to be taken to safeguard vulnerable adults from abuse.

There were systems in place to respond to complaints and to take appropriate action when necessary.