Archived: Carlton Hall Residential Home

Carlton Hall Residential Home is a care home accommodating up to 86 older people in one adapted building. There were three units in the service, one in the main part of the building, another

two were newer extensions called The Granary and The Bakehouse, and a unit, The Courtyard, specifically for people living with dementia. 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 domiciliary care service.

During this inspection, there were 78 people living in the residential home and there were 9 people using the domiciliary care service provided to private bungalows in the grounds.

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

People were supported by sufficient numbers of staff that had been recruited safely and had checks undertaken to ensure they were suitable for their role.

Staff were following good infection prevention and control practices which helped to minimise risks to people.

Staff had received infection control training and competency checks were undertaken to ensure staff compliance with the provider's infection control policy and current guidance.

On arrival at the home, visitors had their temperatures taken, were observed washing their hands and were provided with PPE to ensure visits were safe.

Staff assisted people to keep in touch with friends and family. The provider had set aside three rooms which visitors could access without going through the building and had installed floor to ceiling screens, comfortable seating and a telephone. This meant people would be able to see their visitors in comfort in the colder weather.

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

Rating at last inspection

The last rating for this service was Good (published 31 December 2018).

Why we inspected

This targeted inspection was prompted in part due to concerns received about staffing levels at the home. A decision was made for us to inspect and examine those risks. 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 coronavirus and other infection outbreaks effectively.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

This was a comprehensive inspection. The first day of our inspection on 29 November 2018 was unannounced. The second day of our inspection on 3 December 2018 was announced. During this inspection, there were 53 people living in the residential home, some were living with dementia, and there were 17 people using the domiciliary care service provided to private bungalows in the grounds.

At our previous inspection of 20 and 27 March 2018, this service was rated inadequate overall. The key questions for effective, caring and responsive were rated requires improvement and the key questions for safe and well-led were rated inadequate. There were breaches of Regulation 9: Person centred care, Regulation 14: Meeting nutritional and hydration needs, Regulation 12: Safe care and treatment and Regulation 17: Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We took enforcement action by placing conditions on the provider’s registration. These conditions asked the provider to send us monthly audits on health and safety and care plan documents and the actions they had taken to improve.

The service was placed into 'Special measures' by CQC. Services placed in special measures are inspected within six months. If insufficient improvements are made, we would have taken action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This would have led to cancelling their registration or to varying the terms of their registration within six months if they did not improve. The service was kept under review and if needed could have been escalated to urgent enforcement action.

Following our inspection in March 2018 we met with the provider and they told us about their plans for improvement, in addition they submitted an action plan which identified how they planned to implement improvements. At this inspection of 29 November and 3 December 2018, we found that the service had significantly improved overall and there were no breaches of regulations.

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.

People were provided with their medicines when they needed them. There were systems in place to manage people’s medicines safely. Improvements had been made in how the staff recorded how people were provided with medicines prescribed to be administered externally, including creams.

Improvements had been made in how the risks to people were assessed and staff were guided how to reduce these risks. Staff were trained in safeguarding people from abuse and where incidents had happened the service learned from these and used the learning to drive improvement.

There were systems to ensure that there were sufficient numbers of care staff to meet people’s needs. Staff recruitment processes reduced the risks of staff being employed in the service who were not suitable. People were supported by staff who were trained and supported to meet their needs.

There were infection control systems to reduce the risk of cross contamination. The environment was well maintained and suitable for the people using the service.

People had access to health professionals when needed. Staff worked with other professionals involved in people’s care. People’s nutritional needs were assessed and met. Improvements had been made in how the risks associated with people’s dietary needs were assessed and reduced.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.

People shared positive relationships with staff. People’s privacy, independence and dignity was respected. People were listened to in relation to their choices, and they and their relatives, where appropriate, were involved in their care planning. Improvements had been made in how people’s care was assessed, planned for and met. People’s choices were documented about how they wanted to be cared for at the end of their life.

People’s had access to a variety of social activities to reduce the risks of isolation and boredom. There had been recent changes in how the activities were provided.

There was a complaints procedure in place and people’s complaints were addressed.

The registered manager had a programme of audits which demonstrated that they assessed and monitored the service provided. Where shortfalls were identified actions were taken to improve. People were asked for their views about the service and these were valued and listened to. As a result, the service continued to improve.

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.

Carlton Hall residential home is registered to provide accommodation and personal care for up to 56 people. At the time of our inspection there were 50 people using the service. The service comprises a main residential home [which also includes a separate unit for people living with dementia], and a building external to the main residential home called "The Granary". People using the service were older adults whose needs were associated with physical disability, dementia or long term conditions.

The service also provides personal care to the owners of 25 purpose-built modern bungalows located within the grounds of Carlton Hall, if they require this.

There was a registered manager in post. 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.

Following the comprehensive inspection on 30 November 2016, we served a warning notice on the provider in relation to the staffing levels in the service which posed risks to people's safety. The warning notice included a timescale by when compliance with the legal requirements must be achieved.

We undertook this focused inspection to check that the provider had made improvements to meet the legal requirements in the warning notice, within the given timescale. This report only covers our findings in relation to the warning notice and those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Carlton Hall on our website at www.cqc.org.uk.

Other issues identified in the November 2016 inspection under the domain 'Safe' were not followed up at this inspection. We will review our rating for 'Safe' at the next comprehensive inspection.

The provider had responded promptly to our concerns regarding staffing levels. They had increased the number of staff during the day and at night across the service.

People’s dependency levels were assessed against the number of staff available on each unit. New admissions were considered alongside the current needs of people using the service. This meant that the management team would be aware of any potential impact on the wider service.

Staff had been provided with training in dementia care, which included behaviours which may challenge staff.

Activity provision for people using the service had improved. The main activity co-ordinator had returned from leave, providing more robust oversight of what was being delivered and ensuring that activities met the needs of all people using the service. Care staff were able to interact with people in a more meaningful way.

Personal care could also be provided to the owners of twenty five purpose-built modern bungalows located within the grounds of Carlton Hall, if they required this. Their care was provided by Carlton Hall care staff, but people could also choose their own provider if this was their preference. There were 11 people receiving the personal care service at the time of the inspection.

There was a registered manager in post. 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.’

During this inspection, we found that the registered provider was in breach of three regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The provider had not ensured that there were sufficient numbers of skilled and knowledgeable staff to meet people’s needs. Staffing levels were not always adequate to ensure that people were kept safe at all times.

Staff were kind and caring in their interactions with people. However, at times care was task focussed and hurried with staff unable to respond to people as quickly as they would like.

There were gaps in how the service assessed and monitored the quality of its provision. Whilst there were some quality assurance mechanisms in place, not all aspects of the service were being effectively monitored.

Staff received training relevant to their role, but needed further training in relation to dementia care. We have made a recommendation about the specialist needs of people living with dementia.

The dining experience was not conducive to an enjoyable mealtime and opportunity for social interactions. We have made a recommendation about improving the dining experience for people.

People’s care records were updated and amended to changing needs. However, not all records included guidance for staff on how to support people with their emotional and social care needs. Having this information would help staff to tailor individual needs more fully.

People were asked for their consent before any care, treatment or support was provided.

Risk assessments were completed to ensure that people were kept safe. These included risk assessments in relation to people's personal care, moving and handling, falls and medicines.

Systems were in place for managing medicines and people received their medicines in a timely manner. However, protocols were not in place for people receiving their medicines ‘as required’.

Activity provision was not sufficient to meet the individual and specialist needs of people using the service.

People's individual needs were not always met by the design or decoration of the service. We have made a recommendation on improving the design and decoration of accommodation for people living with dementia.

Staff had knowledge of safeguarding adult's procedures and what to do if they suspected any type of abuse, and who they should report this to. Safe recruitment procedures were in place, and staff had undergone recruitment checks before they started work to ensure they were suitable for the role.

People and relatives said if they needed to make a complaint they would know how to. There was a complaints procedure in place for people to access if they needed to.

There was an open and transparent culture in the service. Staff felt listened to and were able to raise their views openly.

We found that improvements had been made in relation to staff training and supervision and did not find any evidence to substantiate the concerns that had been raised with us.

During the course of the inspection, we spoke with nine people who used the service, three staff members, the registered manager and the provider.

The people we spoke with told us that they were well cared for and that the staff treated them with respect. Our observations of the care being provided confirmed this.

Risks to people's health, safety and wellbeing had been assessed and action had been taken where risks had been identified. People who used the service had access to healthcare professionals to meet their healthcare needs when required.

Staff had received training in a number of areas to ensure that they provided safe and appropriate care to the people who used the service. The staff we spoke with told us that they were happy working at the service. We saw that staff had received formal supervision.

We found that some improvements had been made.

New staff members recruited to the service received induction training in line with the recommended requirements of the care sector. The majority of staff had recently received formal supervision. However, a number of existing staff had not received refresher training to ensure that their skills and knowledge were up to date to enable them to deliver safe and appropriate care.

Plans were in place to deliver a new quality assurance monitoring process across the service. This was to be implemented from September 2013.

The care records we checked were accurate, up to date and subject to regular review.

We spoke with six people and two relatives about the service. One person told us, 'They (the staff) are marvellous, they work very hard, they are very very good indeed.' Another person said, 'I am happy with my care, they know I want to do things and they let me do it.' A further person told us, 'Oh they (the staff) are brilliant, they really look after us well.' One relative said, 'I am generally satisfied with the care.' Another relative told us, 'The staff are lovely.'

We saw that staff interacted with people in a kind and caring manner. People had access to other healthcare professionals such as doctors, speech and language therapists and district nurses when needed. This showed that the service responded to changes in people's health needs.

The service was clean and tidy on the day of our inspection and the premises were well maintained.

Appropriate checks were being made of the staff employed by the service. However, not all staff had completed their mandatory training and there was no formal supervision taking place.

Resident and relative's feedback in relation to the care and treatment provided was requested by the service on an annual basis. However, no documented audits were being carried out.

We checked four people's care plan records and found that some areas of them were inaccurate.