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Inspection summaries and ratings from previous provider

Overall summary & rating


Updated 20 July 2017

The inspection took place on 31 May and 1 June 2017 and was announced. We gave the registered manager one working days’ notice of the inspection as the location is an extra care service and we needed to confirm the registered manager would be available when we inspected. The service has 35 flats and each person has their own tenancy. One flat had two people sharing and one flat was vacant.

The housing support is provided by Hanover Housing which also provides support in terms of catering and activities. In the past four years, the service has had three different care providers. The current care provider, Carewatch, began providing a service in February 2016. For the staff, the change in care providers has meant ongoing changes in processes and record keeping which staff told us had been difficult.

People had their own flats based in a community setting within an extra care housing complex. The service provided support to people in their own homes with additional flexible care and support services available on-site to enable people to live as independently as possible. Support included personal care and support with medicines, meal preparation, shopping and cleaning. At the time of the inspection there were 35 people being supported by the service.

This was the service’s first inspection since becoming registered with the Care Quality Commission in July 2016.

The service had a registered manager. The registered manager had been with the service for eight years and had been the registered manager for four years. 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.

PRN (as required) medicines protocols were not kept in the people’s flats with their medicines administration records (MAR). We recommended that the provider develop systems in line with the Royal Pharmaceutical Society guidance on the management of medicines to ensure the proper and safe management of medicines at all times.

People using the service said they felt safe. The service had appropriate safeguarding policies and procedures in place and staff were aware of how to respond to any safeguarding concerns. We saw risk assessments and management plans in place to minimise the risk to people using the service.

There was an adequate number of staff to meet the needs of the people who used the service.

The service was working within the principles of the Mental Capacity Act (2005). People were happy with the level of support they received and told us they were involved in their day to day care decisions.

Support workers had inductions, supervision, appraisals and relevant training to support the people using the service.

Stakeholders we spoke with said the registered manager and team leader were accessible and responsive.

The service had a number of systems in place to monitor and manage service delivery and staff performance. There was a complaints system, people felt able to raise concerns and satisfaction surveys were completed.

Inspection areas


Requires improvement

Updated 20 July 2017

The service was not always safe.

Where people had PRN (as required) medicines, people�s files lacked PRN protocols.

Staff understood whistleblowing and knew how to respond if they suspected abuse.

There were sufficient staff to meet people�s needs.



Updated 20 July 2017

The service was effective.

The service worked within the principles of the Mental Capacity Act (2005) and people were able to make decisions for themselves.

Staff had relevant training and supervision.

Peoples� nutritional needs were met.

People had access to health services.



Updated 20 July 2017

The service was caring.

The service provided end of life care, but there were no advance end of life records.

All stakeholders said the staff were kind and caring.

People felt they were listened to, could make choices and that their dignity was respected.



Updated 20 July 2017

The service was responsive.

People�s preferences were discussed with them and recorded.

People had up to date care plans and reviews.

People knew how to make a complaint.



Updated 20 July 2017

The service was well led.

There were data management systems in place to monitor the effectiveness of the service and that people�s needs were being met.

The registered manager and the team leader knew the people using the service and their needs well.

The registered manager and team leader were approachable and all stakeholders we spoke with said they listened.