Caroline 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

People received safe care from staff who knew them well and understood their risks and how best to support them. Systems were in place to keep people safe from abuse and harm. Some processes and documentation were in need of improvements, these were fully discussed and addressed by the end of our assessment. For example, the documentation to support people's mental capacity and best interest decisions were not clear and were in need of a review. We saw that people at risk of falls had sensor mats, low beds and 1-1 support. People received their medicines safely and in line with good practice guidelines. Staff were recruited safely to ensure they were suitable for their roles. Staffing levels and deployment of staff were discussed and the registered manager has agreed to review staffing levels/deployment at night to reduce the potential of falls.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Not everyone could speak to us in respect of the experiences of living at Caroline House. One person told us, "I am safe here, very good really, I'm only here for a short time I hope until my husband gets better." Another told us, "Very safe here." A relative told us, "I haven't got any concerns, if I have a grumble, I tell them, and it gets sorted"

Staff were able to discuss what they learnt from accidents and incidents to manage the on -going risks and how they communicated these with the team. For example; lessons learnt were discussed in staff meetings, supervisions and daily handovers. Staff told us, "If someone has an accident or a fall, we look at the how, and possible cause and then ensure we try everything to prevent it happening again," and "One of our ladies is not settling and managed to learn the codes to doors and got in to the garden, we have sought advice, informed GP and social services, changed the codes and at present is on one to one support, We do discuss incidents and accidents, we receive training of how to report on it and follow it up."

Processes for investigating, analysing, and responding to accidents, incidents, complaints, and safeguarding alerts were in place. Accidents and incidents had been recorded as they happened and analysed by the management team to determine the cause, and actions had been planned to reduce the likelihood of recurrence. For example, for one person who had recurrent falls, there were records of strategies put in place, such as, consultations with GP, district nurse and the frailty team. There was also reference to the equipment introduced to manage the risk, which included sensor mats, floor level bed, and crash mat. Lessons learnt were discussed during staff meetings, enabling staff to reflect and share ideas of how to improve things further. There were systems in place for families, people and staff to raise concerns or share their views. The service had a service improvement plan in place which detailed plans for ongoing improvements. Events within the home were recorded and learning was discussed in staff supervisions and team meetings. Staff told inspectors about the role of equipment to keep people safe. This included the use of call bells, and the importance of checking people had these on their person in all areas of the home to reduce the risk of harm. The registered manager analysed accidents and incidents for trends

Relatives told us the staff knew and understood what support their relative required, and confirmed that their loved one regularly saw health professionals such as chiropodists, district nurses and doctors. Relatives also told us how staff and the registered manager supported them to follow up on any treatment plans they had previously been given by health professionals. For example, managing weight loss, and skin care.

Staff told us, "We send the care plan with the resident if they go to hospital, we also send the medicines with them," and "We do have a procedure to follow when anyone goes to hospital, it's part of our training as well, It's standard that any admissions are met before they arrive, because we need to know we can look after them properly."

Feedback from health professionals was mixed, we were told, “Staff contact us if they need any advice and do follow our guidance,” and "Staff don’t always accompany us when we visit, I'm not sure if its due to not enough staff or not understanding that we need them to ensure identity and reassure the patient, especially when we haven't met them before." A visiting chiropodist said "I have not noticed any thing that worries me, the residents are happy and looked cared for, the staff are always polite."

When people moved to the home from a stay in hospital or the community, for either short term or long term agreement, a pre-admission assessment was undertaken. This was to ensure that it was a safe transfer and that Caroline House had the facilities, equipment and staff knowledge to meet the persons' needs. People’s health needs were detailed in their care plans and risk assessments and guidance was in place to guide staff. The registered manager and staff told us how they worked well with other health and social care services to ensure people received timely care and all information was shared with professionals. For example, when people had specific health needs, medical advice was sought to ensure staff knew how to support people safely. The management team worked to ensure continuity of care, including when people moved out of the service and on to new placements. When people were supported to go to hospital, the care plan document which identified their care needs accompanied them, along with the medicine administration chart. We were told there was also a 'This is me' document that also was sent with them which detailed their communication and social needs. These ensured that hospital staff have vital information about them and their health. However, not all people had a completed 'This is me document'. We were told that this would immediately be addressed. There were policies and procedures in place to support staff to understand when to refer people to other health and social care services and we saw examples of where this had been completed in a timely way.

People told us, "I am safe here, nice place." Relatives told us, "Totally safe, they have made me able to relax because I know my relative is safe." "They contact me, if there has been an accident, always able to raise anything and I know they are diligent, no concerns about safety, or raising any concerns if I needed to."

Staff we spoke to were confident and knowledgeable about safeguarding. They knew how to notice signs that abuse may be occurring and how to raise alerts and report concerns, by whistleblowing if necessary. Staff knew people well and could describe their difficulties and how to support them individually. One staff told us, “The managers' not here very much, so I would got to the senior in charge.” Another staff member said, "We have regular training refresher courses to keep their knowledge up to date. We are very aware of what to look out for, most of our residents are vulnerable, that is why they are here."

We did not observe any safeguarding concerns during our site visit. People appeared relaxed and comfortable around staff, and staff were observed speaking to people in a kind and considerate way. Staff supported people to make choices about their meals and how they spent their time. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). We observed some people had restrictions placed on their movement. For instance, sensor mats and 1-1 support. This was to promote their safety and prevent harm and these restrictions were lawful.

Staff were knowledgeable and confident about safeguarding processes. They understood their safeguarding responsibilities to keep people safe, how to challenge discrimination and report any concerns. They knew how to recognise the signs of potential abuse and knew how to raise alerts and report concerns, by whistleblowing if necessary. Staff knew the people they supported well and how to support them individually. The management team explained that people’s capacity was assessed in accordance with the Mental Capacity Act (MCA) and assessments were stored within people’s records. There was a safeguarding and whistleblowing policy in place, and staff confirmed they had read the policies as part of their induction and training. We saw that procedures had been correctly followed, and the provider had made referrals as required to the local authority and notified CQC appropriately. There was a file kept by the registered manager of all the DoLS submitted and their status. The service worked within the principles of the Mental Capacity Act (MCA) and if needed, appropriate legal authorisations were in place to deprive a person of their liberty (DoLS). Records reflected MCA assessments had been undertaken to consider people’s capacity to make decisions about their care. Care plans contained information about where decisions were being made in people’s best interests, and the reasons for this. We identified that improvements were needed to the documentation as it was not always clear as to people's capacity to make certain decisions. The registered manager told us this had been identified and a decision made to change the care planning systems, which included the MCA assessments. DoLS applications and authorisations were in place for people around any restrictions within their lives that they did not have capacity to consent to. Systems to review these were also in place and we could track those that were due to be renewed.

People were not able to share their experiences so we spoke with family members during the assessment process. "I am able to relax now, knowing that my relative is safe, previously, in a different setting I could not relax and was always worrying," and "I am happy with the care given to my relative, but I'm not sure I have ever been involved in discussing the support but I talk to them all the time"

Staff were able to discuss risk to individual people and told us, "We have care plans and risk assessments, that tell us of how to look after them and we get support from the seniors when we need it. If someone has a fall, we re-look at everything , we use sensor mats for some people, so we get alerted when they are up and can support them."

We observed staff promoting people’s independence, safety and attending to people promptly when they needed assistance. Equipment had been well maintained and regularly serviced. We did see some moving and handling poor practice during the visit, the staff however after two failed attempts and advice, did correct themselves, and the move was done safely." This was discussed with the registered manager and further training and support was to be given to staff.

Each person had a computerised care plans and risk assessments, which included guidance for staff on how to support people safely and minimise risks. However, they were not all fully reflective of the care required to ensure they received consistent safe care. For example, for one person, it stated they had limited physical ability and were unable to walk. There was a mention of a motorised wheelchair but no mention of other support needed in respect of moving safely. We also found very little guidance or monitoring of the management of behaviours that distress. There was information regarding peoples mental capacity but this was not consistent and some were misleading. We found gaps in records relating to behaviours caused by distress, which meant that staff may be unaware of potential triggers, and how to respond in the most supportive and effective way. This was acknowledged and addressed by the registered manager during our assessment process. The registered manager undertook an analysis of incidents and accidents and referrals were made for additional support where required, for example, in reach team, falls team, assistive technology, and GP involvement. Systems and procedures were in place for unusual events, such as fire, loss of power, and other emergencies.

Relatives told us that the environment was safe. One relative said, “It has a locked door and codes to make sure no one gets in that shouldn’t and no one leaves if they shouldn’t. I don’t worry that they will leave without staff knowing, there is space for them to walk around without getting into trouble.” Another relative told us, “I think the home is comfortable and well looked after, some areas need re painting but its safe and the furnture is good."

Staff understood the process to report and record any maintenance issues with equipment or in the environment of the home. Staff told us maintenance issues were addressed and shared no concerns about the condition of the home or the safety of equipment. One staff member told us, “Any issues we find, we tell the senior and write in the maintenance book. Whenever the maintenance people are in the building, they will come and do the jobs. The equipment is checked on a regular basis, the hoists, the stand aids, wheelchairs and the beds are all checked."

The premises were free of obstacles and hazards, and we observed some people moving safely and independently without any staff assistance around the care home, some people used electric wheelchairs and walking aids. We observed staff assisting people with equipment that was well maintained, and found there were areas to improve to ensure staff moved people safely. This was fully discussed with the registered manager, who would ensure staff received further training and support.

People lived in a safe and secure environment that met their identified needs. There were established systems in place that ensured the environment and equipment was safe, this included daily, weekly and monthly checks and audits of the environment and equipment. The provider had recently completed essential work from a recent fire risk assessment report. Staff completed fire training yearly and undertook regular fire evacuation drills and any learning from them had been taken forward to improve practice and confidence. All staff received health and safety training and checks had been undertaken to ensure safe management of utilities, food hygiene, hazardous substances, moving and handling equipment, staff safety and welfare. There was a business continuity plan which instructed staff on what to do in the event of the service not being able to function normally, such as a loss of power or evacuation of the property. We reviewed records of checks which showed where concerns had been noted appropriate action had been taken to rectify any issues. There was a maintenance book in place for staff to record any concerns they found.

People and relatives spoke positively about the staff team. One relative said, “The staff are nice here, friendly and cheerful”. Another told us, “I am reassured by the staff here, caring and respectful.” We asked about staffing levels and some comments we received were, “I don’t have any concerns, always seem to be staff around.” and “I think more staff are needed as sometimes it takes ages for some to let us in or out.”

We received mixed responses from staff about staffing levels. Some staff told us that they needed more staff especially as they have people who need 1-1 support to remain safe. They also said that they had noticed that night staff don’t always have time to check people in the morning, due to two staff being needed for two people on 1-1 and two staff for 21 other people. They told us, “Sometimes people are very wet in the morning, I think staffing needs to be increased both night and day, especially for emergencies, our residents can be very active at times.”

We observed that staffing numbers were stretched on the morning of the first day of the assessment. Staff told us it was due to a person now placed on 1-1 support following an incident at the weekend. The registered manager later confirmed that despite extra staff being brought in, a member of staff had been off sick and said she had not been informed of this, and that had made them short of staff. There was always a staff member in the communal lounge area, this was sometimes the member of staff who was supporting a person on 1-1, but we did not observe people being at risk at these times. Staff were visible and available to support people’s requests for help and take the time to sit with people, to assist them with food and drink if necessary. There were delays on answering the door bell but that was due to staff being with people and not leaving them unattended.

The provider used a dependency tool to identify safe staffing levels. Duty rotas showed staffing levels were maintained across the home. However, we were not fully assured that they reflected people's individual needs at specific times of late evening and early morning. Accident and incident records from January 2024 to October 2024 identified that most recurrent falls /incidents happen early morning on waking or late evening up to midnight. We fed this back to the registered manager, who agreed to review the staffing numbers for these times of the day. We also found that rotas did not reflect the hours that the manager was in the premises, nor who was the dedicated fire warden or first aider. The registered manager immediately updated the rotas to ensure that these details were visible to all staff. There were three people who were commissioned 1-1 support and their needs were being met. Staff had the skills and knowledge they needed to provide safe support to people. Staff had completed training, new staff had completed an induction programme, essential training and received competency checks to ensure their training had been put in to practise before working independently. Records showed that staff received regular supervision and appraisals. This was also confirmed by staff. The provider had robust and safe recruitment practices in place to make sure all staff were suitably experienced, competent and able to carry out their role before being employed. This included obtaining references and checks with the Disclosure and Barring Service (DBS). The DBS helps employers make safer recruitment decisions and helps prevent unsuitable people from working in care services.

People and their relatives told us the home was clean and that staff were good about wearing gloves and aprons. One relative said, “Staff wear gloves and apron, even hair covering when serving food and drink.” One relative said, “It’s always clean and I've never noticed any odours, some areas need a lick of paint, but the lounge and dining room are very nice.”

Staff told us that they received training and received updates re infection control at team meetings. Comments included "We get training and have plenty of stock of gloves and aprons -always available," and "House keepers are really good here, they do a really good job."

The home was clean, and the housekeepers were observed cleaning all areas of the home following good practice guidance -however there were areas that were difficult to clean due to poor décor. This was mainly in corridors and doors. We observed some poor practice in the use of gloves and aprons. On two occasions care staff left people's rooms following personal care wearing blue gloves and aprons and pushing person in wheelchair into the communal areas. On another occasion, staff entered a persons room wearing gloves and apron from serving food and drink and assisted the person and then entered the managers' office wearing the same gloves and apron. this was fed back to the registered manager who took appropriate and has since confirmed the staff had received further training and competency supervisions. Other practices with infection control safeguards were good The management of catheter equipment was not following good practice guidance, we found the catheter bag on a stand in their bedroom and the tubing was uncovered and trailing on the floor. This was reported immediately to ensure it would not be reconnected to the persons' catheter as this would be a potential source of cross infection.

People's rooms were cleaned regularly by housekeeping staff, 7 days a week and people and visitors commented positively, with no-one reporting any problems with the standard of cleanliness of the environment and equipment. Staff were trained in the use of personal protective equipment (PPE) and of the importance of good hygiene practice. The manager told us they ensured staff continued to follow Public Health England guidance to reduce the risk of COVID-19 reoccurring. People had received COVID-19 booster injections. People’s laundry was managed well and the laundry room was clean and well organised. All staff understood their responsibility to reduce the risk of infection and followed infection control guidance. There were posters and training to assist staff in keeping up to date with any changes to infection control measures. Audits were completed to ensure compliance with the procedures and policies of the home.

People were not able to share their views about medication, but one family member we spoke with said, “Staff do keep us informed of any changes and we discuss them. I have no concerns.”

Staff told us they complete training before administering medicines and then have to pass a regular competency assessment. One staff said, “We take medicine giving very seriously, and we do lots of checks to make sure it is right, If we don’t know what a drug is for we look it up, .” Another staff member said, "It's important we are not interrupted when we give out medicines, we get training, and we are observed managing medicines to ensure we follow correct guidance."

Medicines were managed safely. The clinical room was clean and well organised. Medicines were stored safely as per manufacturer's guidance in lockable cupboards and clinical fridge. Temperatures of both room and fridge were recorded daily. There were policies and training in place to ensure staff managed people’s medicines safely. The hospital admissions and discharge policy, reminded staff of the importance of a safe handover with any medicine changes recorded. There was a covert medicines policy in place for anyone who needed this, with clear explanations for staff should it be required. Staff who gave medicines had the relevant knowledge, training and competency that ensured medicines were handled safely. We observed staff giving medicines safely and were recorded accurately. Risk assessments were in place for certain medicines. All discrepancies and medicine errors were recorded and investigated and action taken as required. Daily and monthly audits were carried out, and any shortfalls were addressed. Protocols for 'as required' (PRN) medicines such as pain relief medicines were in place, apart from two peoples. This was immediately addressed.