Carlton Hall Residential Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. This service does not provide nursing care. Carlton Hall Residential Home accommodates up to 60 older people in one adapted building. There were three units in the service, one in the main part of the building, another was a newer extension called The Granary, and a unit specifically for people living with dementia, although people living with dementia also lived in the main and Granary units. The service is also registered to provide personal care in a domiciliary care agency to people living in their own homes in the purpose built bungalows on site. We also inspected the personal care service. This was an unannounced comprehensive inspection. During this inspection of 20 and 27 March 2018 there were 53 people living in the residential home, some were living with dementia, and there were 15 people using the domiciliary care service.
There was 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 registered manager told us that they would be stepping down from the role of registered manager and was undertaking the head of care position. The application to cancel their registration had not yet been sent to us. There was a manager in place for the residential care home and a manager for the domiciliary care service. The manager for the care home told us that they would be making an application with us to be the registered manager.
At our last comprehensive inspection of 30 November 2016 this service was rated overall as Requires Improvement. We identified a breach of Regulations in relation to the standard of the care plans, staffing and the quality assurance processes. We issued a warning notice in respect of the concerns about staffing. The provider wrote to us and told us the improvements they intended to make. We carried out a focussed inspection in March 2017 to check on the staffing situation and found that the provider had made the necessary improvements.
You can read the reports from our last inspections, by selecting the 'all reports' link for Carlton Hall Residential Home on our website at www.cqc.org.uk.
An incident had happened in the service which is subject to an investigation and as a result this inspection we did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk to people relating to avoidable harm. This inspection examined those risks.
During this inspection of 19 and 27 March 2018 we checked that the provider had made improvements following our comprehensive inspection of 30 November 2016. We also checked that the improvements identified in our focussed inspection of 9 March 2017 had been sustained. We found that the service had maintained staffing levels in the service to meet people’s needs. However, we found shortfalls in the service and improvements had not been made in relation to the governance systems and the way that people’s care was assessed, planned for and met. We also identified that there were continued breaches of regulations relating to the provision of personalised care and the governance of the home.
The provider and the management team had failed to make adequate improvements in the service to provide people with safe and good quality care at all times. The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:
• Ensure that providers found to be providing inadequate care significantly improve.
• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.
• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.
Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains 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 the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will 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 we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.
The service did not have robust systems to identify when people were at risk of avoidable harm. Because of this the processes in place did not support the provider and management team to address the risks and develop systems to reduce them. This meant that people were at potential risk of harm. There were systems in place to ensure people were provided with enough to eat and drink. However, where people were at risk of choking, the service did not have processes to adequately identify and act on risk.
The systems for monitoring the service were not robust enough to independently identify shortfalls and to support the provider and management team to continually improve the service people received. The service had missed the opportunity to use the learning from our previous inspection and an incident to improve the service.
The service had accepted the support from the local authority to improve their care plans. However, people’s care plans did not provide guidance for staff on how people’s needs were to be met. This included people’s conditions and how these affected their daily life. The records maintained by staff to identify how people’s needs were met were not detailed enough to show that people were provided with the care they needed to meet their assessed needs. This included the records kept to evidence that people were receiving good end of life care. We found that the care plans for the people who used the domiciliary care service provided guidance to care workers to meet people’s needs.
People had access to health professionals, where required. However, the service had not always followed up referrals when people were at risk of harm. Staff worked with other professionals involved in people’s care.
Improvements were needed in the safe management of medicines. There were shortfalls in the recording to show that people had received their medicines as prescribed. Records identified that people were not always provided with their prescribed creams. In addition the guidance for staff relating to the creams were not always clear.
There were infection control processes and procedures in place which reduced the risks of cross infection. However, we identified some areas needing improvement to reduce the risks to people.
Improvements were needed in the environment. This included signage to support people to navigate around the service. We also identified some areas of risk in the environment. Once these were pointed out they were addressed immediately.
People were supported by staff who were trained and supported. Staff supported people in the least restrictive way possible; the policies and systems in the service supported this practice.
People were treated with respect and compassion by the staff working in the service. People had positive relationships with the staff who supported them. However, due to the shortfalls identified during our inspection we were not assured that people were provided with a caring service at all times.
People were provided with the opportunity to participate in activities that interested them. However, we saw that there were times, outside of the planned activities, that people were disengaged. Staff listened to what people said and acted on their wishes.
There was a complaints procedure in place and people understood how to raise concerns.
Staffing levels in the service were organised to provide people with assistance when they needed it. Recruitment of staff was done safely and checks were undertaken on staff to ensure they were fit to care for the people using the service.
You can see the actions we have asked the provider to take in the full version of this report.