Archived: Consensa Care Limited - Colegrave Road

At this inspection on 13 November and 02 December 2013 we found the provider had made the necessary changes to ensure people's needs were identified, planned and delivered to their satisfaction.

At our last inspection on 06 June 2012 we found that the system in place to identify, assess and manage risks to the health, safety and welfare of the people who used the service and others was ineffective. The system in place to regularly assess and monitor the quality of service provided was also ineffective.

At this inspection on 13 November and 02 December 2013 we found the provider had systems in place to identify, assess and manage risks to the health, safety and welfare of the people who used the service, and had implemented a new quality assurance system which was quality focused. This system however had not been implemented for sufficient time for us to assess how robust and effective it was.

protected their rights. The system in place to identify, assess and manage risks to the health, safety and welfare of the people who used the service and others was ineffective and the system in place to regularly assess and monitor the quality of service provided was ineffective.

We judged that this had a major impact on people who used the service and we served two warning notices on the provider on 25 January 2013 relating to care and welfare of individuals and quality monitoring. These two warning notices required the provider to become compliant by 04 February 2013.

We undertook a follow-up inspection on 27 February 2013 to check compliance with these two warning notices and found that the provider was still non compliant in both areas. As a result of this we have taken further enforcement action to protect people who use services from any further harm.

At this inspection on 06 June 2013 we found the provider had made most of the changes necessary, however we still had concerns that staff had not always delivered care in line with people's care plans or sufficiently supported people with all of their health care needs, which potentially put people at risk of harm.

We judged that this had a major impact on people who used the service and we served two warning notices on the provider on 25 January 2013 relating to care and welfare of individuals and quality monitoring. These two warning notices required the provider to become compliant by 04 February 2013.

We undertook a follow-up inspection on 27 February 2013 to check compliance with these two warning notices and found that the provider was still non compliant in both areas. As a result of this we have taken further enforcement action to protect people who use services from any further harm.

Care plans were person centred however one person who had lived in the home for a short period of time had no care plan, risk assessment or initial assessment of needs available for inspection.

Some people's risk assessments lacked important information. Staff showed a good understanding of people's needs but this did not always include appropriate risk taking.

Some areas of the home were in need of redecoration and refurbishment; the nominated individual said these works were scheduled for completion in the first four months of 2013.

Quality assurance systems and the management of the home were ineffective. Some records were incomplete and information was not always readily available.