The inspection took place on 12 and 13 March 2018 and was announced. This was the first inspection since the service was registered with the Care Quality Commission (CQC). We gave the provider, Hales Group Limited, 48 hours’ notice of our inspection. This was because the location provided a domiciliary care service and we needed to be sure the registered manager and staff would be available to support the inspection process.

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. The CQC does not regulate premises used for extra care housing; this inspection looked at people’s personal care and support service.

People who used the service lived in a large building which had 156 individual flats. At the time of the inspection, there were 10 vacant flats. Hales Group Limited provided domiciliary care to people with a range of needs. These included people with mental health needs, physical difficulties, those who were living with dementia, older frail people or those who had a learning disability. Not everyone using Redwood Glades received a regulated activity. The CQC only inspects the service being received by people provided with ‘personal care’, for example, help with tasks related to personal hygiene and eating. Where they do, we also take into account any wider social care provided. At the time of the inspection, 118 people were receiving the regulated activity of personal care from Hales Group Limited.

The service had a registered manager in post. A registered manager is a person who has registered with the 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 Act 2008 and associated regulations about how the service is run.

During this inspection, we identified shortfalls throughout the service in relation to medicines management, quality monitoring of the service, records and staff support, supervision and training.

We found people had not always received their medicines as prescribed. There had been a number of errors with medicines management and staff were to receive additional training and competency checks.

Improvements were required in risk management to ensure all areas of risk were identified and included in care plans to help staff minimise risk of incidents and accidents.

The unit manager told us part of the internal quality monitoring system had ceased in October 2017 as they concentrated on an influx of admissions to Redwood Glades. This meant any audits that were completed were carried out in a reactive rather than a planned way, for example to address errors in medicines management. This meant care plan and risk assessment deficits had not been identified and addressed quickly. Seven day and six-week reviews with people who used the service had taken place, which was part of the audit system.

Records were not comprehensive, especially those describing the care required to support people in a safe way. There were also some gaps in recording decisions relating to people’s capacity. We have made a recommendation about the application of the Mental Capacity Act 2005.

The above issues were breaches of Regulation 12 Safe Care and Treatment and Regulation 17 Good Governance, of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. You can see what action we told the provider to take at the back of the full version of the report.

Improvements were needed to make sure staff received formal supervision to check their progress and development. We have made a recommendation about this.

Staff were recruited safely and in numbers sufficient to meet people’s needs. The registered man