Archived: Colney Lodge Limited

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.

This is a summary of what we found:

Is the service safe?

We found that people's needs had been assessed and met appropriately. They received their medicines regularly and on time. The provider had a robust recruitment policy and procedures and had carried out the required checks before an offer of employment had been made. People's confidential records had been kept safely and securely.

Is the service effective?

We spoke with the two people who lived at the care home. Both people told us that they were happy with the care and support they received. One person said "The staff remind me to take my medicines and they are very caring and supportive." The other person said "I like living here. The food is good. The staff are helpful and I have no concerns. We are well looked after."

Is the service caring?

People told us that there needs had been met and that the staff were supportive and helpful. We observed the staff interacting with people in a friendly but professional manner. One person said "The staff discuss my care plan with me and I am involved in the decisions about my care and support." The other person said "The staff prompt and encourage me to maintain my personal care as much as I can." Both people told us that the staff respected their privacy and dignity.

Is the service responsive?

The care plans we reviewed demonstrated that people's need had been assessed when they first moved to the care home. Reports from other professionals had been used as part of people's care plans. People attended the local day centre during part of the week and they received regular visits from their family and relatives. People attended their regular Care Programme Approach meetings and they said that they were able to make decisions for themselves.

Is the service well-led?

The home carried out an annual questionnaire survey for people using the service, their relatives and other professional. The feedback from the surveys had been positive. People said that they had regular house meetings and discussed issues relating to the day to day running of the home and that they felt that their views were listened to and acted on.

We found that the provider was meeting the standards we reviewed. People had been cared for in safe and accessible surroundings that promoted their wellbeing. Staff had received appropriate training, professional development and supervision so that people's welfare needs had been met by competent staff. There was a quality assurance system in place to assess and monitor the quality of service provision.

We found that the provider was meeting all the standards we reviewed. People's needs had been met appropriately. There had been safe systems in place for the administration of medicines. There had been a recruitment policy and procedure in place and we noted that the required checks had been carried out for all employees. We saw that records had been held safely and had been securely destroyed when appropriate to do so.