Archived: Carisbrooke

Updated 31 May 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection was completed by 3 inspectors.

Service and service type

Carisbrooke is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Carisbrooke is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. We used all of this information to plan our inspection.

During the inspection

We spoke with 5 people who used the service and 1 relative about their experience of the care provided. We spoke with 4 members of staff including the manager, and care workers.

We reviewed a range of records. This included 5 people's care records and 10 medication administration records. We inspected 3 staff files in relation to their recruitment. A variety of other records relating to the management of the service, including audits and policies and procedures, were also reviewed.

We inspected the environment and spent time observing interactions between people and staff, and infection prevention and control practices.

Updated 31 May 2023

About the service

Carisbrooke is a residential care home providing personal care and accommodation for up to 12 people who may be living with a learning disability and autistic people. Accommodation is provided over 3 floors. At the time of the inspection 10 people were using the service.

People’s experience of using this service and what we found

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. 'Right support, right care, right culture' is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support

People were not supported to have maximum choice and control of their lives, staff did not support them in the least restrictive way possible and in their best interests; policies and systems in the service did not support this practice. Staff did not always follow the Mental Capacity Act key principles when making best interest decisions.

Medicines were not always managed safely. The provider did not give people care and support in a safe, clean, well equipped, well-furnished and well maintained environment that met their sensory and physical needs. Some areas of the home were visibly dirty.

Right Care

The provider did not ensure they always had enough appropriately skilled staff to meet people's needs and keep them safe. People could not always take part in activities and pursue interests that were tailored to them. The provider did not give people opportunities to try new activities that enhanced and enriched their lives.

Staff did not always receive training to enable them to meet the needs of people and keep them safe. However, we observed kind and caring interactions between people and staff during inspection.

Right Culture

There was a lack of effective monitoring in place and this had resulted in poor outcomes for people using the service. Ineffective quality monitoring systems had failed to pick up and address the failings we identified during our inspection. There was a lack of oversight and leadership within the home.

People were not involved in developing the service. We have recommended the provider seeks advice and guidance to meet people's sensory and emotional well-being needs. The culture of the service did not always enable staff to continuously learn and improve. For example, lessons learned from incidents were not always analysed and shared with staff.

The service was not able to demonstrate they were meeting the underpinning principles of right support, right care, right culture. Staff were not aware of the right support, right care, right culture guidance.

The manager was open and responsive to concerns raised during the inspection.

For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 7 August 2019).

Why we inspected

We received concerns in relation to health and safety, risk management, infection control and good governance. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Carisbrooke on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to medicine management, risk management, consent, infection control and good governance at this inspection. We have also made a recommendation in relation to training, design and decoration to meet people’s needs.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.