Archived: Colney Lodge Limited

Updated 27 July 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.'

This inspection took place on the 05 February 2016 and was unannounced.

The inspection team consisted of one inspector.

Before the inspection, we reviewed information we held about the service, including the notifications they had sent us. A notification is information about important events which the provider is required to send to us.

During the inspection we spoke with the manager, one carer, the two people who used the service. We looked at the care records of both people and the recruitment and training file for two staff employed at the service. We also reviewed the provider’s policy documents, medication records and accidents and incidents records.

Updated 27 July 2016

We carried out an unannounced inspection on 05 February 2016.

Colney Lodge is registered to provide accommodation and personal care for up to two people with mental health needs. At the time of the inspection, there were two people being supported by the service.

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 overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The service was rated as inadequate because there were no clear risk assessments in place that gave guidance to staff on how risks to people could be minimised and how to safeguard people from the risk of possible harm. This was a breach of Regulation 12: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Safe Care and Treatment.

People’s medicines had been managed by staff but staff did not always complete the documentation appropriately. Incidents had not been reported to the relevant agencies in a timely manner. This was a breach of Regulation 17: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Good governance.

Staff did not receive regular supervision and support. Staff had been trained to meet people’s individual needs although training records were not available for all staff employed at the service. This was also a breach of Regulation 17: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Good governance.

The provider had effective recruitment processes in place and there were sufficient numbers of staff to support people safely but DBS checks were not current. Staff understood their roles and responsibilities and sought people’s consent before they provided any care or support. However, not all staff had an understanding of how they would use the Mental Capacity 2005 and Deprivation of Liberties Safeguards (DoLS) when providing care to people. This was a breach of Regulation 18: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staffing.

The manager did not always understand their responsibility in reporting to CQC, any issues they were required to report as part the regulations for caring out the regulated activity. This was a breach of Regulation 18 of Care Quality Commission (Registration) regulations 2009.

People were supported by staff who knew them well, but they felt that the staff were not always respectful towards them.

People’s needs had been assessed, but care plans were not clear and did not always take account of their individual needs, preferences, and choices. The service supported people with health care visits such as GP appointments, optician appointment, chiropodists and hospital visits.

The provider had a formal process for handling complaints and concerns. They encouraged feedback from people but did not always act on the comments received in order to improve the quality of the service. The provider did not have effective quality monitoring processes in place to ensure that they were meeting the required standards of care.