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Archived: Consensa Care Limited - Highbury Gardens

Inspection Summary

Overall summary & rating

Updated 1 June 2015

We carried out an unannounced comprehensive inspection of this service on 9 April 2014. A breach of legal requirements was found. As a result we undertook a focused inspection on 19 January 2015 to follow up on whether action had been taken to deal with the breach.

You can read a summary of our findings from both inspections below.

Comprehensive Inspection of 9 April 2014.

Consensa Care Ltd - Highbury Gardens provides personal care and accommodation for up to six people with a dual diagnosis of mental health and substance abuse needs. People who use the service may neglect their basic needs and place themselves at risk of harm. The service aims to support people with their health needs whilst providing a safe and stable living environment. It is based in a large house with a garden in a residential area. Each person had their own room and the use of shared communal areas. The condition of the home was checked during the inspection and it was clean and well maintained.

At the time of the inspection, the manager of the home, who has been in post since July 2013, was not registered with the Care Quality Commission (CQC). The provider told us the current manager was due to apply to the CQC for registration. The Commission is keeping the situation under review and will take further action if necessary to ensure the service has a registered manager.

During the inspection we spoke with all five of the people who lived at the home. They told us the service had helped them. For example, one person said they enjoyed living in the home. They told us that they were supported to follow their interests. They said, “I have been here a good few years and have done some good art work whilst here. I feel calm.” Another person’s social worker had written to the home stating, “I have been greatly impressed by your long-standing commitment to X’s care and dealing with the challenges they present.”

People and the community mental health teams who supported them were involved by the home in the process of planning support to meet their individual needs and preferences. Each person’s support plan explained how staff supported them to keep healthy and safe and to undertake activities of their choice. People told us they had regular meetings with a support worker which helped them. One person said, “I can raise any issue at all with my key worker.”

Some people told us that they found living in the home ‘boring’ and said they did not get enough assistance to improve their quality of life through involvement in worthwhile activities. People’s records showed that staff had worked with them to encourage them to choose and undertake activities such as going to the gym and the library. However, people had not always continued with their chosen activities. People told us they had ambitions to find work. For example, one person said they wished to be a bricklayer. These long term goals were not reflected in people’s support plans.

During the inspection all the people who used the service went in and out of the home as they wished. They told us they were free to come and go at all times. One person said, “I do what I want to do. The staff cannot stop me.” There were no restrictions on people that came within the scope of the Deprivation of Liberty Safeguards.

People told us they felt safe most of the time but said that on occasions there were incidents when they had been frightened and had lost personal items. They said staff had dealt well with these situations. Reports showed that the provider had taken appropriate action to recompense and safeguard people when such incidents occurred.

People said they were given support with their medicines. Staff had completed records which showed that people were given appropriate support and they received their medicines safely.

People told us the provider asked them about their views of the service. Notes of meetings confirmed some changes had been made in response to their views. A person told us, “the manager has made a few good improvements.”

Staff told us that they thought the way the home was managed had improved since the current manager has been in post. They told us they felt well trained and received good support from their managers. They said they thought there were sufficient staff on duty to meet people’s needs safely.

The provider had made regular visits to the home to speak to people and to ensure staff working to their required standards. This included checks that people’s support plans and risk assessments were accurate and up to date.

The provider had a copy of their complaints procedure on the noticeboard. Notes of keyworker sessions and other meetings showed that people’s complaints were frequently discussed and they were offered support by staff to make complaints. However, given the number of complaints that people had raised which the provider was aware of, and the fact that no formal complaints from people had been logged, it was evident people had not been effectively supported to make use of the provider’s complaints procedure, as required by law.

Additionally, records showed that the Care Quality Commission had not been notified of all the incidents in the home that could affect the health, safety and welfare of people. There was a breach of two health and social care regulations, and the action we have asked the provider to take can be found at the back of this report.

Focused inspection of 19 January 2015

Following our inspection on 9 April 2014 the provider wrote to us to inform us what action they had taken to meet the standards. We undertook this inspection to check that the provider had followed their plans to meet the legal requirements. We found that the provider had followed the plans and that the provider was now compliant with regulations. People who used the service were aware of how to raise a complaint in line with company policy. We also found that the provider had notified the Care Quality Commission of all allegations of abuse and incidents investigated by the police in a timely manner. This meant that the legal requirements were being met.

We found that people were at risk of fire due to unsafe management of smoking in the service. However, the manager had an action plan to address this and we saw that steps had been taken to reduce the risk.

The manager in post at the time of the inspection was not registered with the CQC, however following the inspection the manager has applied for her Disclosure and Barring Service check and was awaiting its return before submitting her application to CQC. We will be monitoring the application process.

Inspection areas


No action required

Updated 1 June 2015

9 April 2014

People who use the service were protected from abuse and avoidable harm. Staff understood their responsibility to take action to safeguard people. People were free to come and go from the home as they wished. There were no restrictions to their liberty.

People told us about some occasions when they had not felt safe. A person said, “I was frightened at the time, but its ok now.” The provider had dealt with these incidents appropriately and taken follow up action to improve people’s safety.

People and their community mental health teams were involved by the service in assessing and reducing risks to people. These had been updated regularly to ensure people were protected from harm.

People received their medicines safely as prescribed. Staff kept accurate medicine administration records, which showed how people had been supported with their medicines.

19 January 2015

People were not safe from the risk of a fire. People smoked in their personal rooms using the floor, window sills and table tops to extinguish their cigarettes.

The home had in place a no smoking policy, however further to the inspection the provider has informed us that they are in the process of amending the smoking policy and liaising with the local fire prevention officer to minimise the risk.


No action required

Updated 1 June 2015

(Text unchanged from comprehensive inspection)


No action required

Updated 1 June 2015

(Text unchanged from comprehensive inspection)


Improvements required

Updated 1 June 2015

9 April 2014

People said they had been asked by the provider what they thought about the home. They said some changes had been made in response to their views, which had made them feel more respected by staff.

People raised some complaints with us during the inspection. However, they had not used the provider’s formal complaints procedure. We have asked the provider to ensure people are supported to use this.

19 January 2015

We found that action had been taken to ensure the service was responsive.

The provider had effective systems in place to ensure that people understood who to contact if they wanted to make a complaint and what the processes were after a complaint had been made.


Enforcement action

Updated 1 June 2015

9 April 2014

People and staff told us that management arrangements at the home had improved since the current manager took up her post in July 2013. However, at the time of the inspection she had not yet applied for registration with the CQC.

The quality of service people received at the home was regularly checked by the provider. People were supported by sufficient staff with appropriate skills.

The provider had dealt with incidents appropriately but had failed to notify CQC of all serious incidents at the home.

19 January 2015

The provider had regularly informed CQC of all serious incidents and those being investigated by the police. We had received statutory notifications in a timely manner and where appropriate action plans were recorded and implemented.

The home does not have a registered manager in place. A manager is in post however there has been no registered manager since May 2014. At the time of the inspection the provider was interviewing applicants for the position of being registered with the CQC.