This inspection took place on 31 July, 1, 3 and 10 August 2018. The first day was unannounced and the other days were announced. Carlton Dene is a ‘care home’ that provides personal care and accommodation for older adults. People living at the service require care and support as they are living with dementia and/or are frail due to chronic health difficulties and/or physical disabilities. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during the inspection. Carlton Dene can accommodate up to 42 people and 40 people were living at the service at the time of the inspection. The premises are purpose built and divided into four separate units. People are provided with a single bedroom with en-suite facilities and shared communal areas. The service provides permanent placements and respite care.At our previous inspection we had rated the service as Requires Improvement. Safe, caring and well-led had been rated as Requires Improvement and effective and responsive had been rated as Good. We had issued two breaches of regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to dignity and respect, and good governance. We had also made three recommendations in relation to the use of topical medicines and the medicine fridge temperature checks, determining the correct staffing levels and meeting people’s end of life care needs. Following the previous inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe, caring and well-led to at least Good. At this inspection we found that the provider had met the breaches and recommendations.
At the time of the inspection the registered manager was on maternity leave. A registered manager is a person who has registered with the CQC 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 provider informed us that they were in the process of recruiting an interim manager. Temporary management arrangements were in place until an interim manager commenced at the service and completed their induction.
At this inspection we found that improvements had been achieved in relation to the use of topical medicines and medicines were being stored at the correct temperatures, in line with the manufacturers' instructions. We saw that prescribed topical applications were being stored securely in people's bedrooms and staff were correctly completing topical medicine administration records (MARs). We noted that some staff needed guidance to ensure they properly supported people to take their respiratory inhalers, which was discussed with the provider during the inspection. We were aware that there had been medicine errors since the previous inspection and saw that recent improvements had been made to the management of medicines, and actions were in place to support senior care staff to safely administer medicines. At the time of the inspection staff were being closely supported by the regional care development manager but this was a temporary measure and another medicine error occurred during the inspection. Therefore we could not be assured that systems were embedded to ensure the effective governance of medicines.
People told us they felt safe and at ease with staff. Records showed that staff had attended safeguarding adults training and were aware of their responsibilities. Safeguarding notifications were appropriately sent to CQC, in accordance with legislation.
Risk assessments had been developed to identify and mitigate risks to people's safety and wellbeing.People's risk assessments were in the process of being reviewed, and updated where necessary. However, we noted that risk assessments were not always sufficiently robust to adequately promote people's safety and wellbeing.
The safety of the premises had been addressed following an incident at the service. We noted some issues in relation to infection control practices. The provider took suitable action to address these issues during the inspection and speak with staff about additional training and support to ensure they adhered to the provider's infection control policy and procedure.
We saw that staff were busy at key points during the day. The provider had increased the number of staff prior to the inspection to ensure that senior care staff had uninterrupted time to focus on the safe administration of medicines. The management team stated that the staffing levels were due to be reviewed. Detailed recruitment practices were in place to ensure that people received their care and support from applicants with suitable skills and experience for their duties.
At the previous inspection we had found that the training matrix did not accurately demonstrate that staff had completed their mandatory training. At this inspection we found that the provider had clear records to show how they monitored staff compliance with their compulsory training requirements. Records evidenced that staff were supported with their roles and responsibilities through training, supervision and an annual appraisal of their performance and development. We received positive comments from visiting health care professionals in relation to how staff supported people to meet their health care needs.
We saw that people were offered choices at meal times and were able to meet with the chef to discuss their dietary needs and wishes, however this meeting wasn't always documented in their care plans. There was some evidence that people could access meals that met their cultural needs, although this area of practice could benefit from being considered in more detail by the provider. We carried out several observations at meal times and saw that people received the support they needed, except on one occasion.
The provider had processes in place to enable staff to assess people's capacity to make decisions and support people to make their own choices, where possible.
Although we observed some positive interactions between people and staff, we observed an incident where people were not supported to make choices.
Interactions between staff and people who use the service were predominantly positive. Staff spoke with people in a kind and gentle way and ensured that their support with personal care was carried out in private rooms with the door shut.
The care plans did not consistently demonstrate that people's needs were identified and understood, so that individual care and support could be planned and delivered. Where care plans had recently been reviewed we saw a more comprehensive and cohesive approach to identifying and addressing people's needs.
People were encouraged and supported to take part in activities, access community resources and engage with music and movement therapeutic sessions. The service had inspired local people to visit as volunteers to enrich the lives of people who used the service.
Complaints were managed in a professional manner and where applicable the provider used their analysis of complaints to learn from their mistakes.
People and relatives we spoke with had no concerns about how the service was managed. They were asked for their opinions at meetings held by the service. We had issued a breach of regulation in relation to the quality of the provider's quality monitoring. The provider had taken action to improve the specific areas highlighted at the previous inspection. At this inspection we found that new areas for improvement were being tackled by the interim management team.
Accidents and incidents were documented and analysed in order to identify and address any concerns.
We have issued three breaches of regulation in relation to the safety of the medicines management, the robustness of risk assessments for people who use the service and the quality of care planning.
You can see what action we told the provider to take at the back of the main report.