Archived: Consensa Care Limited - 167 Chandos Road

The service is registered to provide accommodation and support with personal care to a maximum of seven adults with an acquired brain injury. Six people were using the service at the time of our inspection. The service had a registered manager 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 had systems in place to help safeguard people from the risk of abuse. Risk assessments were in place which included information about how to support people in a safe manner. There were enough staff working at the service to meet people’s needs. Medicines were appropriately stored, recorded and administered.

Staff undertook regular training and had one to one supervision with their line manager. The service worked within the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. People were able to make choices about their daily lives including about what they ate and drank. People had access to health care professionals as appropriate. However, information about people in the event that they were admitted to hospital was often incomplete.

People told us they were treated with respect by staff. The service promoted people’s privacy, dignity and independence.

People’s needs were assessed before they moved in to the service to determine if it was a suitable placement for them and plans were in place which set out how to meet people’s assessed needs. The service had a complaints procedure in place and people were aware of who they could complain to if needed.

People that used the service and staff told us they found the registered manager to be approachable and supportive. Various quality assurance and monitoring systems were in place, some of which included seeking the views of people that used the service.

At our previous inspection in October 2013, we had concerns about the monitoring systems in place at the home. The quality assurance system was not imbedded. During this visit, we found that the quality assurance system had improved and was addressing issues such as poor record keeping, maintenance of the home, handovers and dealing with incidents. We reviewed ten incidents that had occurred between February and 3 March 2014. We found that actions following the incidents were documented and support plans and risk assessments were updated accordingly.

People who used the service confirmed that they had been involved in the development of their support guide and were able to make their own plans for the future. People said they were satisfied with the support staff offered.

Staff we spoke with were knowledgeable about people's needs.

Not all care plans reflected people's needs or offered sufficient information to staff. Care and treatment was not always planned and delivered in a way that ensured people's safety and welfare.

All staff had received supervision and an appropriate induction. However, not all staff were given the support they needed to do their job and no staff had received an appraisal.

A new quality assurance system had been introduced which was quality focused. However, associated audits had not been implemented within the set timeframes and had not picked up on all quality issues.

Care plans offered varying levels of information and guidance to staff. Not all care plans reflected people's needs or offered staff sufficient information. We saw evidence that where there were concerns regarding an individual's safety, these had been risk assessed and measures had been put in place to help minimise the identified risk/s.

There were appropriate arrangements in place in relation to obtaining, recording, handling, safe keeping, disposal and administration of medicines.

There was an appropriate 'Safe Handling of Medicines' policy and procedure in place, which contained a small section on 'promoting independence'.

We found that the majority of staff had received some supervision, but none of the staff had received the organisations expected level of one supervision every six to eight weeks.

Decisions about care and treatment were made by appropriate staff at the appropriate level. Staff were aware of their responsibilities, when to seek advice and the delegated levels of authorisation.

There was no effective quality assurance system in place, however the provider was aware of the need to develop a robust quality assurance system and actions had been taken at an organisational level to address this shortfall.

People's diversity, values and human rights were respected. We saw evidence of individual care plans reflecting their specific requests. One person wanted to be supported to make traditional meals that reflected their ethnicity; this was provided in the rehabilitation kitchen. Each person had a weekly slot allocated to them where they were either supported or supervised with making a meal.

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People we spoke with told us that they enjoyed attending a local projects and day trips out, and 'everything was fine'.

People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. We saw evidence of the provider's quality assurance system. We examined the provider's policy folder that contained policies that were in date. We were provided with a folder that contained details of audits conducted by the providers. Examples include a care plan audit and a daily record audit.

Staff told us that they felt staff worked well as a team, and was supported by their manager.