Cartref House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had not always had robust systems in place to support the service’s safety culture. Prior to the inspection CQC identified some concerns with risk monitoring following incidents. Details of safety measures taken to manage people’s risks during incidents had not always been recorded to evidence staff actions due to limitations in the providers electronic monitoring systems. The registered manager told us they had recently introduced paper records in response to the issues found and this required embedding.

Leaders reviewed accidents and incidents through monthly meetings and a dashboard that enabled them to compare incident types and trends. Records showed some reflective discussions about triggers, successful strategies and actions following incidents. However, there was not always evidence that robust review had taken place to address accuracy of records or assess whether actions during incidents were effective to reduce distress or agitation or whether lessons could be learnt.

A provider audit from July 2026 also confirmed that although lessons were learnt, staff recording needed to improve. Although leaders had begun strengthening systems, these improvements were not yet fully embedded.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored, including when people moved between different services.

The service worked with people and external professionals to support safe systems of care. Pre-admission assessments considered people’s needs and their compatibility with others living at the service. Staff used handovers, hospital passports, risk assessments and care plans to share information amongst the staff team and with relevant others where appropriate. They supported people to attend appointments and access mental health and primary care services. A professional told us the service communicated emerging concerns before they became significant problems and supported people through their care pathways.

The provider generally protected people from abuse and avoidable harm. Safeguarding referrals had been made to the local authority; the service responded appropriately to concerns and maintained records.

The management team reviewed incidents to identify whether further reporting was required. Staff understood different forms of abuse and knew how to report concerns both internally within their service and externally to other relevant agencies. Staff had completed safeguarding training and safeguarding was discussed at team meetings. People appeared comfortable with staff during the inspection, and positive interactions were observed.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. Leaders and staff understood the principles of the MCA and acted in line with these.

The provider did not always work well with people to understand and manage all risks. Staff did not always provide care to meet all of people’s needs that was safe and supportive.

Risk of constipation had not always been well managed for a person. There was no risk assessment or care plan in place to guide staff on how to monitor or mitigate the person’s risk. Records showed the person experienced periods of constipation. They had not always received support to manage this risk despite staff monitoring the person’s bowel movements and noting a period of 4 days without a movement. The person had ‘as required’ medicine prescribed for this condition, but it was not administered on this occasion. We discussed this with the registered manager who told us they would take action to put guidance in place for staff and review processes to ensure constipation was consistently managed in future.

People had detailed risk assessments and care plans covering other areas of their needs such as their personal care, physical health and community access. Positive behaviour support plans were in place to guide staff on how to support people’s emotional well-being and understand their actions. Staff knew people well and used individual strategies such as reassurance, sensory items and distraction to support people when they were distressed or agitated.

The service supported people to take positive risks. For example, they supported a person who previously had continuous supervision with a gradual reduction in supervision to enable them to develop skills to manage their own risks and support which promoted their independence.

The provider identified and managed environmental risks, and the premises were clean and mostly well maintained.

Some people living at the service had heightened risks relating to the environment. Staff were vigilant about these risks and appropriate checks were in place to monitor this such as daily checks of the home. Gas and electrical safety checks had been completed. A fire risk assessment had been carried out with remedial works completed. Personal emergency evacuation plans were available, and staff and people participated in fire drills. Shared bathrooms required refurbishment, and the provider was obtaining quotations.

There were enough qualified, skilled, and experienced staff to meet people’s needs.

During the inspection we observed there were enough staff to meet people’s needs. Staffing was based on assessed and funded support, including 1-to-1 and 2-to-1 support. People and staff told us they felt there were enough staff to meet people’s needs. A person told us there were enough staff to support their daily tasks.

The registered manager told us there were vacancies at the service and staffing levels were being maintained with some agency staff use. They had identified a pattern of increased incidents when some people were supported by agency staff because agency staff did not have the same knowledge or rapport with people. The registered manager had put measures in place to reduce the risk of this with regular staff supporting people when they were unsettled or distressed and were trying to recruit to fill their vacancies.

Staff knew people well and how to meet their needs, although some refresher training for staff had not been completed within the providers specified timeframe. The registered manager was aware of this and had booked some staff on training to bring this up to date.

Staff had been recruited safely with relevant pre-employment checks in place, as required, to ensure staff were safe and suitable to work at the service. Staff received supervision to support them to carry out their roles.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider assessed and controlled the risk of infection. People’s individual risks in relation to infection prevention and control (IPC) were assessed and measures in place to ensure risks were managed safely.

The home was clean and tidy. Cleaning schedules were in place, including night-time cleaning, and staff completed IPC checks during shifts. We observed people were supported to take part in cleaning their rooms and communal areas. People were also supported to maintain their laundry in line with IPC.

Staff had completed IPC training and discussed infection control risks during team meetings. The provider completed IPC audits to maintain oversight that staff followed IPC practice. Food hygiene arrangements were in place to promote safe food standards including routine checks and temperature monitoring.

The provider ensured people received their medicines and treatments safely overall.

People received their regular medicines as prescribed. We observed and people told us staff involved them in their medicines administration. Staff explained medicines to people and supported independence where appropriate such as people reading the names of their medicines and counting the number they were taking.

People had access to other ‘as required medicines’ (PRN) for example to manage pain. Relevant guidance was in place to support the safe administration of people’s PRN medicine. We found an issue where 1 person had not always received their PRN medicine in line with guidance to consistently manage their risk, this has been reflected under the ‘Involving People to Manage Risks’ quality statement.

Staff had received medicine administration training and had their competency assessed.

Medicines were stored securely including controlled drugs which were double-locked. The provider’s medicine administration records were electronic.

The provider had experienced some issues with their electronic medicine management system in relation to discrepancies with stock levels. They were working with their medicine system provider to try to address the ongoing issue and staff carried out frequent stock checks to monitor the stock levels and investigated any discrepancies. This issue was ongoing at the time of the inspection.