Carlton 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 requires improvement. At this assessment, the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Carlton House promoted a strong and positive learning culture. Leaders and staff placed clear value on reflection, improvement and continual learning, and this was evident in the way the team approached risk, challenges and change.

The service had effective systems in place to identify trends and patterns across incidents, daily records and safeguarding concerns. Staff understood why learning from these trends was important and could explain how this information helped them improve practice and prevent issues from recurring. This demonstrated learning was embedded rather than reactive.

Positive risk‑taking was encouraged and supported. Staff told me people were not restricted unnecessarily, and risk was approached in a balanced and person‑centred way. Where things did not go to plan, setbacks were not viewed as failures. Instead, they were treated as opportunities to gain further insight into what worked well and what needed to be adapted. This approach helped staff feel confident in promoting independence while maintaining safety.

The service had effective mechanisms for sharing lessons learned. Staff received feedback through team meetings, reflective discussions, formal supervision and ongoing mentoring provided by the registered manager. This ensured learning was communicated consistently and staff had the opportunity to discuss how it applied to their day‑to‑day work. Staff reported they felt supported, valued and encouraged to develop their skills.

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

The provider had clear and thorough processes to assess and plan for people’s needs prior to admission. Holistic assessments considered the individual’s needs, and the potential impact of a new admission on people already living at the home. This ensured people were admitted to the service safely and sensitively, with minimal disruption to others.

People had key documents in place, such as hospital passports, which contained personalised information about their health needs, communication preferences and how they wished to be supported. This ensured professionals had immediate access to essential information when people required support from other services. This meant people did not need to repeatedly share their personal history, and the risk of inconsistent or unsafe care during transitions was reduced.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People were supported by staff who were vigilant, compassionate, and confident in their responsibilities. Risks were well managed, concerns were identified early, and safeguarding processes were consistently effective.

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 home was working within the principles of the MCA and how DoLS were managed. Staff had a good understanding of people’s personalised risks and safeguarding needs. They were able to clearly describe the specific vulnerabilities of each person they supported, including risks related to communication, health conditions, behaviour, and social situations. Issues were identified quickly and staff followed the organisation’s procedures and informed the registered manager without delay. The registered manager demonstrated strong oversight of safeguarding. They assessed concerns promptly and took proportionate action based on the level of risk. They made timely referrals to the relevant external agencies, including the local authority safeguarding team and health professionals. Lessons learned were shared with staff, which strengthened the home’s safeguarding culture.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff actively involved people in understanding and managing risks associated with their care and daily lives. The provider used recognised tools to identify potential hazards and establish a clear foundation for safety planning. These assessments considered a wide range of factors, including environmental risks, health-related concerns, behavioural triggers and safeguarding issues. This ensured staff had a comprehensive and up-to-date understanding of each person’s needs.

Staff used this information to collaborate with people, supporting them to understand identified risks and agree practical, personalised strategies to keep themselves and others safe. People were encouraged to share their views, preferences and concerns, and staff supported them to make informed decisions about how risks should be managed.

Risk management plans were applied consistently, and staff reviewed them regularly with people. Reviews included discussion of any changes in behaviour, health or circumstances, with plans updated promptly to reflect new information. One staff member told us, “We have behaviour support plans to guide us. I can recognise early changes, and sometimes giving space is all it takes. Other times, light humour helps, and some people have PRN (as required medication) in place as a back-up. We always work with the least restrictive option first.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The registered manager maintained a safe and well‑managed environment, including when people’s behaviours during periods of distress resulted in unplanned damage to the home. Staff responded promptly to maintenance issues, and repairs were completed in a timely manner to ensure the environment remained safe, functional and comfortable for people.

The maintenance person had previously worked in a support worker role, which enabled them to engage positively with people while carrying out maintenance tasks. During the assessment, we observed the maintenance person supporting someone to paint their shoe rack using a supportive, hand‑over‑hand and encouraging approach. This interaction promoted inclusion, independence and meaningful involvement while addressing maintenance needs.

This approach ensured environmental risks were managed proactively and proportionately. People were able to continue using their home safely with minimal disruption, and staff demonstrated confidence in responding to environmental changes quickly and effectively. The registered manager showed good practice in maintaining a safe environment through prompt action, effective risk management and strong leadership oversight.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider had safe and effective staffing arrangements in place. Safe recruitment practices were followed consistently, including completing appropriate background checks, verifying employment histories and obtaining suitable references before staff began working at the service. This ensured that only suitable and trustworthy individuals were employed to support people.

Staff told us they felt confident in their roles and had access to regular supervision, support and development opportunities. Training records showed that staff completed learning to equip them to carry out their responsibilities effectively, and new staff were supported through a structured induction process.

We saw staff working well together as a team, communicating clearly and sharing information to ensure people received consistent and safe care. One staff member told us, “We always have enough staff. They’re very thorough when recruiting new staff to make sure they have the right attitude and values to complement the team. Even staff who have joined without experience have had the right approach and have developed really well. I am really impressed with the staff team.”

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.

A clear understanding of current infection prevention and control (IPC) guidance was demonstrated, and appropriate measures were in place to reduce the risk of infection spreading throughout the service. Risks were reviewed regularly, and the manager acted promptly when concerns were identified, ensuring relevant agencies were informed without delay.

Staff understood their responsibilities and consistently followed safe practices, including good hand hygiene, the correct use of personal protective equipment (PPE), and effective cleaning routines. One staff member told us, “We are fully stocked [with PPE]. We receive a delivery weekly.”

Carlton House successfully implemented IPC measures without compromising the homely environment. Communal areas were clean and hygienic while remaining warm, personalised and welcoming. People’s bedrooms retained their individuality and personal character, alongside consistently high standards of cleanliness.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines safely and in a timely way. Medicines administration was recorded accurately on people’s medicines administration records (MARs), and medicines were stored safely and securely. Robust processes were in place to support the safe and effective use of medicines. Staff had access to detailed, person‑specific guidance for medicines prescribed to be taken as required (PRN), which supported consistent and safe administration.

We identified a gap on a MAR for a single medication; this had been promptly identified during an audit and appropriate action taken. Medicine quantities and stock balances were checked following each administration, which meant we could be assured that the correct doses were administered and accurately recorded by staff.

The use of topical creams and ointments was clearly recorded on MARs, with body maps in place to guide staff on the correct sites of application. Temperature monitoring records were maintained in line with national guidance to ensure medicines were stored safely.

People were seen by their GP at least once a year and were supported to have any checks required to monitor their health. Hospital passports were in place for each person, supporting continuity of care when people accessed other health services.

There were clear processes for recording and reviewing medicines‑related incidents or errors. Staff administering medicines were appropriately trained and supported, and a formal observation of medicines administration was completed and recorded at least annually. Managers and suitably trained staff regularly completed medicines audits to ensure procedures were followed and to support continuous improvement.