This comprehensive inspection took place on 7 March 2018 and was unannounced. The last inspection took place in March 2017 and the service was rated ‘requires improvement’ in Safe, Effective, Well Led and overall but we did not find any breaches in relation to the Regulations. Caring and Responsive were rated ‘good’. During this inspection, we found that improvements had been made on the areas identified at the last inspection but further improvements were required. We have rated the service ‘requires improvement’ in the key questions of Safe, Effective, Responsive, Well-Led and overall.

Sitara Haven is a ‘care home’ for up to three people with learning disabilities. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of the inspection, three people were using the service.

The person who owns the home is registered as an individual and manages the home. Therefore the home does not require 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.

During the inspection we found people had risk assessments and management plans in place to minimise risks and incidents. These were reviewed annually but the risk management plans were not updated to show there was an evaluation of the risks people faced and the effectiveness of the management plans to mitigate the risks

Care workers followed procedures for the management of people’s medicines and underwent medicines training. Medicines audits were in place. Care workers had completed medicines competency testing but it was not clear what this involved and it did not include administering insulin injections. Therefore we could not be sure people were receiving their medicines safely as prescribed.

The provider did not always comply with Mental Capacity Act (2005) principles as an application for a Deprivation of Liberty Safeguards authorisation was not applied for. However we saw care workers were responsive to people’s individual needs and preferences. Additionally there was no indication that people’s end of life wishes had been considered as part of the care planning and consent forms were not fully completed.

Care plans were reviewed annually and involved people using the service but the paperwork was not up to date, so we could not be sure peoples’ current situation and preferences were recorded. In addition, the language used in the care plans was not always person centred.

The provider did not have effective quality assurance procedures as checks and audits did not identify concerns highlighted in the inspection.

We found four breaches of Regulations during the inspection. These were in respect of safe care and treatment, consent to care, person centred care and good governance. You can see what action we told the provider to take at the back of the full version of the report.

People’s rights to make decisions were not always respected and their independence was not always promoted.

The provider had procedures in place to protect people from abuse. Care workers we spoke with knew how to respond to safeguarding concerns.

Care workers had completed training in health and safety and used protective equipment as required.

Care workers had up to date relevant training, supervision and annual appraisals to develop the necessary skills to support people using the service. Safe recruitment procedures were followed to ensure care workers were suitable to work with people using the service.

People indicated they were happy at the service and care workers knew peoples’ likes and dislikes and

The inspection took place on 21 March 2017 and was unannounced.

The last inspection took place on 15 March 2016 at which time we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to employing fit and proper persons and staff appraisals. At the inspection of 21 March 2017, we found improvements had been made to meet the regulations.

Sitara Haven is a care home registered to provide accommodation and personal care for up to three adults. The service supports people with learning disabilities and / or mental health needs. At the time of the inspection there were three people using the service.

The person who owns the home is registered as an individual and therefore the home does not require 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.

We found people’s files did not record if they had the capacity to make specific decisions or if they had consented to their care.

Training was up to date, however not all staff understood the principles of the Mental Capacity Act (2005). Additionally one member of staff spoke very little English and we could not be sure they understood the training they had received.

There was a sufficient number of staff, but the provider and their partner worked long hours and we were concerned how this may affect their level of alertness.

Medicines were administered in a safe way but not all medicines were audited weekly and the medicines policy did not include guidelines for PRN (as required) medicines. We recommended the provider develop systems in line with the Royal Pharmaceutical Society guidance on the management of medicines in care homes to ensure the proper and safe management of medicines at all times.

Risk assessments minimised harm to people using the service. However, the service did not have Personal Emergency Evacuation Plans (PEEPs) for each person. The provider said they would action this.

The last Care Quality Commission (CQC) rating displayed, was out of date and the provider agreed they would display the latest rating.

There were procedures in place to safeguard people, staff knew how to respond if they suspected abuse, risk assessments minimised harm to people using the service and the service followed safe recruitment procedures.

Supervisions and appraisals were up to date to develop staff members’ skills to enable them to carry out their duties effectively.

People were satisfied with the menus and were able to have food and drinks when they wanted to.

People had access to health care services and the service worked with other community-based agencies.

We observed staff were kind and respected people’s dignity and privacy.

People received care that was person centred, which meant they were at the centre of decisions that related to their life, and they were involved in reviewing their care. Individual needs and preferences were met and we saw evidence that people accessed activities in the home and the local community.

An appropriate complaints procedure was available. Relatives and staff indicated they could speak to the provider about concerns.

There were a number of service checks carried out to ensure the environment was safe.

The inspection took place on 15 March 2016. It was an unannounced inspection.

The last inspection of the service took place on 18 December 2014 and we made two recommendations. We recommended the provider make resources available to enable and empower the staff team to develop and to drive improvement. We also recommended that the provider ensure they understand and fulfil all the legal obligations of their registration with CQC.

Sitara Haven is a care home registered to provide accommodation and personal care for up to three adults. The service supports people with learning disabilities and / or mental health care needs. At the time of the inspection there were three people using the service.

The provider is registered as an individual and therefore does not require 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 a 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 did not have an up to date Disclosure and Barring Services (DBS) check for one member of staff and they had not carried out any staff appraisals in 2015.

There were yearly reviews that people who used the service were involved in. However, families said they had not been to a review for their relatives in over a year.

People living in the service felt safe. There were procedures in place for safeguarding and staff had attended relevant training.

There were various risk assessments including assessments for finance and smoking. People had individual risk assessments attached to their care plans, which identified risks and the action to be taken.

Supervisions and team meetings were held every three months to discuss and review staff practice and development.

The service was working within the principles of the Mental Capacity Act 2005.

Food and menus was an agenda item for both team and residents’ meetings. People who used the service went with staff to do food shopping and food was cooked freshly in the evenings. Food reflected cultural preferences.

Files had a record of healthcare appointments. Sitara Haven had good communication with the local GP practice and all of the people using the service had been seen in the last six months, accompanied by staff. Medicines were being managed safely.

People who used the service indicated positive relationships with staff. They told us they could talk to staff about any concerns and staff listened. People were involved in their care plans and decision-making.

Each person who used the service had an individual day programme. There were a number of activities on offer in the service and the community.

There were processes in place for the maintenance and monitoring of the service.

The provider had relevant policies and procedures in place that were reviewed yearly.

Staff communicated well with each other and people using the service. Staff knew the needs of the people and there was a family atmosphere in the service.

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

The inspection took place on 16 December 2014 and we gave the provider 24 hours notice of the inspection. This was because the location was a small care home for younger adults who are often out during the day and we needed to be sure that someone would be in. The last inspection took place on 16 November 2013 and the provider was compliant with the regulations we checked.

Sitara Haven is registered to provide accommodation and personal care for up to three adults. The service supports people with learning disabilities and/or mental health care needs. At the time of the inspection the service had no vacancies and the three people using the service had lived there for several years. The provider is registered as an Individual and as such is not required to have a registered manager in place. The provider runs and manages the service.

People who used the service said they were happy with the care they received, as did a relative and stakeholders we contacted. Staff supported people in a calm and gentle manner, treating them with dignity and respect.

People were able to smoke if they wished in a designated smoking room, however the systems in place to protect people who did not smoke were not effective and work was needed to address this.

Staff understood safeguarding and whistleblowing procedures and were clear about the process to follow to report concerns. Complaints procedures were in place and people confirmed they would be happy to raise any concerns they might have.

Recruitment records included all the required pre-employment checks and staff confirmed these had been carried out prior to working at the service.

Staff had received training and demonstrated an understanding of how to recognise and meet people’s individual needs and choices.

Risk assessments were in place and clearly identified the risks to each person and the action to be taken to minimise it. Care records reflected people’s needs and interests and were kept up to date.

Medicines were being well managed and people were receiving their medicines as prescribed. Staff monitored people’s health and accompanied them to healthcare appointments to provide them with support.

People enjoyed the food provision at the service and meals reflected people’s personal and cultural preferences. Activities and outings were organised based on people’s interests and people enjoyed these.

The provider had policies and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). DoLS provides a process to make sure that people are only deprived of their liberty in a safe and least restrictive way, when it is in their best interests and there is no other way to look after them. People using the service had the capacity to make decisions for themselves.

We have made a recommendation about keeping up to date with best practice.

Communication between the provider and the staff was good and they were kept up to date with people’s care and support needs.

Systems were in place to monitor the quality of the service. People and stakeholders were asked for their views and action was taken to make improvements to the service and maintain a good environment for people to live in. The provider was not familiar with all the events notifiable to CQC.

We spoke to three of the people who live at Sitara Haven. They told us that they were happy living in the home and that staff were kind. Their comments included, "staff are nice to me here; I like going out to the high street with staff."

We spoke to a relative of a person using the service who told us, “I don’t think I could find a better place, no complaints.”

Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. We saw evidence that where people using the service were not able to consent, as they had been assessed as lacking capacity, that family members were consulted about care and treatment.

There were arrangements in place to deal with foreseeable emergencies. We saw that there had been a detailed fire risk assessment with clear and comprehensive guidance covering risk of fire. This was evidence that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

Care staff had received training in food hygiene, health and safety and infection control. We saw that the bedrooms and communal areas at Sitara Haven were clean and people were cared for in a clean, hygienic environment

There were enough qualified, skilled and experienced staff to meet people's needs. People

received effective and safe care from suitably skilled staff who understood their individual

needs. We saw records of a very extensive programme of training that all care staff had

taken part in.

We saw care plans, assessments and training records demonstrating that people were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

We spoke with one of the three people living in the home. They told us that they felt safe in the home and that the staff and manager were kind and helpful. Their comments included "I like the home, they look after me,” “the food is good, I like curry” and “its fun here, I like my room.”

We saw that staff supported people using the service in a professional and friendly way. People were offered choices with regard to what time they got up in the morning, the food provided at mealtimes and activities in the local community. One person using the service also told us that they were involved in making decisions. They told us "I can get up when I like and go to bed when I like."

We spoke with two people working at Sitara Haven, including the home's owner. They were able to tell us how they maintained people's dignity, respected their privacy and gave them choices throughout the day. One member of staff commented "this is a good home, we are well trained to do our jobs.” The staff members we spoke with were aware of the risk of abuse and gave appropriate answers when asked about how they would respond if they had concerns about a person using the service.

People we asked told us they are happy at the home and if they have any worries they can speak with staff about them. They told us they enjoy going out for activities such as going to the gym and out for meals. We observed people looked well cared for and appeared content living at the home.