Carrstone House Care Home

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.

The service was in breach of legal regulation in relation to people’s safe care and treatment; the ways people’s medicines were managed and staffing.

This service scored 50 (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.

Accidents and incidents of distressed behaviours were not always clearly recorded on people's care records. This meant that they were not always included in the monthly analysis and audits or investigated. We found that 1 person had experienced a choking incident and that all necessary actions to mitigate the risks of future incidents had not been taken. Some staff spoken with raised concerns that handovers amongst staff lacked detail.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care.

We found that referrals to health professionals such as the Speech and Language Team (SALT), community nurses and Occupational Therapists (OT) were not always made in a timely manner. For example, 1 person had been discharged from hospital in July 2026 on the provision that the service used a specific type of moving and handling equipment to support them with safe transfers, the service did not have this piece of equipment but did not make an OT referral until August 2026.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, avoidable harm, and neglect. The provider did not always share concerns quickly and appropriately. Accidents and incidents were not always well documented. Risk assessments were not always in place and care plans were not always updated as people's needs changed. Therefore, people were not always safeguarded against known risks.

Safeguarding incidents that had been identified by the service had been reported to the local authority.

People said they felt safe living at Carrstone house.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them. We found that not all risk assessments which were needed were in place, for example 1 person who had a lock on their door at night did not have a risk assessment in place for this and it was unclear from their care plan or the daily care notes if they received checks at night.

Risk assessments had been completed for other care and support needs such as choking and mobility and falls. However, 1 person's choking risk assessment said they had a risk of choking and was prescribed a level 5 texture modified diet. While the daily notes showed that they were not receiving a level 5 diet. This was raised at the time with the service, and they responded that the person had mental capacity to decide whether to follow the recommended diet, however their choking risk assessment did not include that they choose not to follow the recommended advice or the risks associated with this choice.

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 service had effective systems in place to monitor the safety of the environment and equipment, any concerns identified were seen to be rectified quickly. People had Personal Emergency Evacuation Plans (PEEPs) in place.

We received positive comments from people who use the service and their relatives about the maintenance person.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

We found that staff had not received regular supervisions.

The service was actively recruiting staff and frequently used agency staff to cover gaps in the rotas. We received a mixed response from people and their relatives, 1 relative said, “There is a severe lack of staff in the evenings. They're really, really short staffed.” While another said,

"Quite a lot of staff turnover, odd occasions seem slightly understaffed." We also received feedback from staff saying they felt rushed and did not have enough on duty this included people having to wait for assistance.

Not all staff were showing on the training matrix, and competency assessments were only completed for medicines and moving and handling.

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 service had effective systems in place to monitor the cleanliness of the home. All areas of the home were observed to be well maintained. Staff had received training on Infection Prevention and Control (IPC), and Personal Protective Equipment (PPE) was available.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. During the first onsite visit we found that medicines stock counts did not always tally with the count that was recorded on Medicines Administration Charts (MARs), with some discrepancies identifying medicine errors had been made which had not been identified by the service. We found that not all medicine allergies were recorded on peoples MARs. We received concerns from people and relatives regarding medicines including finding medicines left unattended in people's rooms and medicines running out.

We raised these concerns at the time and actions were taken to include allergies on MAR charts.