Carisbrooke 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.

This is the first assessment for this service. This key question has been rated requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 59 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff and managers were open, honest, and communicated effectively with the inspection team throughout the assessment.

We found incident reports were not always completed fully and lacked detail. Systems and process had failed to highlight this, which meant lessons could not be learnt or shared with staff for improvement.

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.

We saw evidence that people were assisted to access support from health professionals, for example the GP and psychiatrist. We saw evidence of regular meetings with external professionals and where the service had reached out for advice and guidance on how best to support people.

The provider, and external stakeholders told us of robust transitions when people moved into the service, to try and ensure the move to Carisbrooke House was smooth and supportive. One person told us, “They have done so much to support [person] move into their home, to make sure all their needs would be met due to their complex needs and in the past, risks to staff. Management staff from Carisbrooke attended all professional meetings to ensure they were aware of relevant information, set up a transitions plan and met with the team who previously worked with [person].”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. However, they did not always concentrate 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 potential safeguarding concerns with the appropriate agencies and had a system where this could be evidenced along with actions taken and lessons learnt. However, lessons learnt were not reviewed to see if they were still appropriate, proportionate or relevant.

Safeguarding concerns found during the assessment had not been highlighted or risk assessed by the provider. This placed people at risk of avoidable harm and abuse by external factors, due to poor oversight and management of online safety.

Staff received safeguarding training and said they would not hesitate to report any concerns they had. Staff were able to detail what safeguarding means and what action they would take if they felt there were safeguarding concerns. One staff member told us, “If there are incidents or safeguarding concerns, management take them seriously and ensure they are investigated and addressed promptly. They also provide guidance and learning outcomes to prevent reoccurrence.”

Where applicable, people were subject to a Deprivation of Liberty Safeguards (DoLS). This framework means people can only be deprived of their liberty to receive care and treatment with appropriate legal authority. The provider had a system in place to record these and any conditions or actions that relate to them. There were some restrictive practice measures in place, but these were to promote people’s safety and were legally justified, proportionate, necessary and as a last resort.

The provider did not always work well with people to understand and manage risks. Staff did not consistently deliver care that was safe, supportive or enabled people to do the things that were important to them. This meant people were not always actively involved in decisions about their safety or supported in a way that promoted independence and personal choice.

Risk assessments were in place, but they were not always up to date or reviewed in sufficient detail. This reduced the provider’s ability to ensure that risks were managed proactively and in line with people’s current needs.

Some people had positive behaviour support (PBS) plans in place, and the provider had worked with appropriate external professionals to develop these. However, the risk scoring within these plans was unclear, with no explanation of how the scores had been determined or what they meant in practice. PBS plans had also not been reviewed following incidents to check whether the level of risk had changed or whether additional support strategies were required.

Where physical restraint might be required to promote safety, assessments did not clearly explain when each type of restraint should be used. This created a risk of inconsistent or inappropriate use. We discussed this with the manager, who took prompt action to update the relevant care plans and risk assessments.

We also found that one person did not have care plans in place for their specific and complex health needs. As a result, staff did not have clear guidance on how to support these needs or who to seek advice from if required. This placed the person at risk of receiving incorrect care and placed staff in a vulnerable position when providing support. This was raised with the registered manager at the time, who addressed it immediately.

The provider did not always identify or control potential risks within the care environment. While systems were in place to maintain equipment and facilities safely, there were shortfalls in monitoring day‑to‑day environmental safety that placed people at potential risk.

The provider ensured equipment, facilities and technology supported the delivery of safe care. Records showed that required testing and servicing certificates were in place, and the service had plans to support people in the event of an emergency or disruption. This demonstrated an understanding of the need for safe and well‑maintained infrastructure.

However, during both visits carried out as part of this assessment, we found a fire door propped open. This issue was raised at the first visit, yet the same concern was present during the second visit. Fire doors are designed to prevent the spread of fire and smoke, and propping them open means they cannot close in an emergency, placing people at avoidable risk.

We raised this with the provider, who took prompt action. They ordered suitable, approved equipment that would allow the door to remain open during everyday use but close automatically in the event of a fire. While action was taken quickly once highlighted, the issue had not been identified or addressed through the provider’s own environmental checks.

The provider made sure there were enough qualified, skilled and experienced staff to meet people’s needs safely. Staff received effective support, supervision and ongoing development to carry out their roles. This helped ensure people received care from a confident and competent team who understood their responsibilities.

People told us they completed a thorough induction when they joined the service. This included training relevant to their role, shadowing experienced staff, and time to read and understand care plans, policies and procedures. This helped staff to feel prepared and supported before working independently.

During our assessment, the service experienced staff sickness. This was managed safely and effectively. Initially, the shift lead, who was supernumerary, stepped in to support the team. Staff confirmed this approach was typical, telling us, “There are team leaders on duty to provide leadership and support. If there are any unexpected absences, management arrange cover through bank staff or agency to ensure safe staffing levels are maintained.” This demonstrated clear contingency planning to maintain safe staffing levels.

Staff reported that communication within the team was strong. They told us there were regular staff meetings and handovers, which they described as, “Very open and honest... and we talk about how we can improve.”

The provider had systems and processes in place to assess and manage the risk of infection. Staff had completed infection prevention and control (IPC) training and were able to describe the steps they took to mitigate infection risks. Staff also supported people to keep their rooms clean, and during our assessment we found that communal areas of the service were generally clean.

However, we found some parts of the building required further cleaning and tidying to minimise the risk of infection. These issues had not been identified or addressed through the provider’s own monitoring processes.

Cleaning audits were in place, but where audits had highlighted that required cleaning had not been carried out, it was unclear what action had been taken in response. This meant opportunities to reduce infection risks had been missed, and audit processes were not always effective in driving improvement.

While the provider had laid the foundations of safe IPC practice, the inconsistencies we found meant that risks were not always managed robustly, and further improvement was required.

People were supported to receive their medicines safely and in line with best practice. The provider had systems in place to ensure medicines were administered, recorded and reviewed appropriately. Staff understood their responsibilities and followed procedures that promoted safe medicines management.

Although the medicines policy was out of date, it was in the process of being reviewed. The provider demonstrated that this work was underway to ensure policies reflected current guidance and practice. Staff were able to describe how they followed the policy in day‑to‑day practice, and we saw this translated into safe care.

Staff recorded clear rationales when medicines were missed, and evidence was provided to show this was embedded in practice.

PRN (as‑required) medicine protocols were person‑centred and detailed. The example reviewed contained clear guidance for staff on when PRN medicines should be offered, how the person expressed need, and what non‑medicinal strategies should be tried first. Care plans also included relevant safety information, such as the flammable risks associated with topical creams.

Body maps were in place where creams had been prescribed, supporting staff to apply topical medicines correctly and consistently. Records showed these were completed to a good standard and aligned with the individual’s care plan.

Overall, people benefitted from safe medicines practices delivered by staff who understood the importance of accurate recording, person‑centred guidance and risk‑aware administration. While some documentation required updating and clarification, the systems in place ensured medicines were managed safely and effectively.