• Residential substance misuse service

Archived: Consensa Care Limited - Highbury Gardens

67-69 Highbury Gardens, Ilford, Essex, IG3 8AF (020) 8590 1555

Provided and run by:
Consensa Care Ltd

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Background to this inspection

Updated 1 June 2015

The inspection report contains the findings of two inspections of Highbury Gardens. We carried out both inspections under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspections checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, looked at the overall quality of the service, and provided a rating for the service under the Care Act 2014.

The first was a comprehensive inspection of all aspects of the service and took place on 9 April 2014. This inspection found the service had breached two regulations. The second inspection which took place on 19 January 2015 and focused on the breaches found and action taken by the provider in relation to the breaches found on 9 April 2014.

Comprehensive inspection 9 April 2014.

Before the inspection, we reviewed the information we held on the home. We asked the provider to complete an information return and we used this to help us decide what areas to focus on during our inspection.

At a previous inspection of the home in April 2013 we found that there was not an effective system in place to monitor the quality of the service people received. In addition, staff were not appropriately supported and supervised. We asked the provider to take action to meet the required standards. When we undertook a follow up inspection in December 2013 we found that improvements had been made. A quality monitoring process was in place and staff received on-going training and supervision.  

For this inspection the team consisted of an inspector and an Expert by Experience who had experience of mental health services. We visited the home on 9 April 2014. We spent time observing how people were supported. We looked at all areas of the building and asked a person to show us their room.

During our visit we spoke with all five of the people who used the service. We looked at two people’s records and at information relating to staffing levels and staff training and supervision. We checked the arrangements for storing and administering people’s medicines. Following our visit we spoke to a person’s relative and a health professional who was involved in the care of a person who lived in the home.

Focused inspection of 19 January 2015.

The unannounced focused inspection of Consensa Care - Highbury Gardens took place on 19 January 2015. The inspection was a follow up inspection to check that improvements to meet legal requirements planned by the provider following the 9 April 2014 inspection. The inspection only inspected the service against two of the five questions we ask about the service; is the service responsive and is the service well-led?. We asked these questions because the service was not meeting some relevant legal requirements. The lead inspector for the service carried out the inspection. During the inspection we spoke to four people who used the service, one carer, the manager and the area manager. We looked at the service's policies and procedures, complaints book, complaints form, easy read complaints information, action plans, registration requirements, house meeting minutes, and staff meeting minutes.

Overall inspection

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.