We inspected Carlton House on 11 October 2017. Carlton House is registered to accommodate up to 25 people. It specialises in providing care and support for predominantly older people, many of whom were also living with dementia. At the time of our inspection there were 21 people living in the service. The service was arranged over four floors, with a lift and stair lift connecting all floors. We previously carried out a comprehensive inspection at Carlton House on 8 & 12 September 2016. We found the provider was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because we identified concerns in relation to the management of medicines and record keeping. We also found areas of practice that required improvement. This was because we found issues in relation to staff training, the handling of complaints and systems of governance and quality monitoring. The service received an overall rating of ‘requires improvement’. After this inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to these breaches.

We undertook this unannounced comprehensive inspection to look at all aspects of the service and to check that the provider had followed their action plan, and confirm that the service now met legal requirements. We found improvements had been made in the required areas. However, we did identify further areas of practice that need improvement. The overall rating for Carlton House has been changed to good. We will review the overall rating of good at the next comprehensive inspection, where we will look at all aspects of the service and to ensure the improvements have been sustained.

There was no registered manager in post. The previous manager had left the service in June 2016. At the time of our inspection, no formal arrangements had been made to recruit and register another manager. A registered manager is a person who has registered with the Care Quality Commission 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 and associated Regulations about how the service is run.

Medicines were managed safely and in accordance with current regulations and guidance. There were systems in place to ensure that medicines had been stored, administered, audited and reviewed appropriately.

People were happy and relaxed with staff. They said they felt safe and there were sufficient staff to support them. When staff were recruited, their employment history was checked and references obtained. Checks were also undertaken to ensure new staff were safe to work within the care sector. Staff were knowledgeable and trained in safeguarding adults and what action they should take if they suspected abuse was taking place.

People were being supported to make decisions in their best interests. The registered manager and staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).

Accidents and incidents were recorded appropriately and steps taken to minimise the risk of similar events happening in the future. Risks associated with the environment and equipment had been identified and managed. Emergency procedures were in place in the event of fire and people knew what to do, as did the staff.

Staff had received essential training and there were opportunities for additional training specific to the needs of the service, including the care of people with dementia. Staff had received both one-to-one and group supervision meetings with their manager, and formal personal development plans, such as annual appraisals were in place.

People were encouraged and supported to eat and drink well. There was a varied daily choice of meals and people were able to give feedback and have choice in what they ate and drank. Special dietary requirements were met, and people’s weigh

We inspected Carlton House on the 8 and the 12 September 2016. Carlton House provides care and support for up to 25 older people. On the days of the inspection, 22 people were living at the service. Carlton House provides support for people living with varying stages of dementia along with healthcare needs such as diabetes and sensory impairment.

Accommodation was provided over four floors with a lift and stair lift connecting all floors. Four rooms were double occupancy rooms and two people had agreed to sharing one of these rooms.

The registered manager had left the service at the end of June 2016 and the service was being managed by the area manager who is referred to as ‘the manager’ throughout the report. A registered manager is a person who has registered with the Care Quality Commission 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 and associated Regulations about how the service is run.

People told us they were happy with the arrangements in place for the administration of medicines, however we found medicines were not always managed safely. Some medicines were out of date and staff did not always have guidance to follow for under what circumstances they would administer ‘as and when needed’ medicines to people. Medication administration records (MAR) were not always accurately completed.

Staff received an induction to the service before they worked unsupervised and completed training in subjects the provider considered mandatory, such as safeguarding adults at risk and moving and handling. However staff had not always received the refresher training they needed to make sure they were aware of current good practice guidelines. Staff had not always had the opportunity to meet with their line manager on a regular basis to discuss their training and development needs.

There was a complaints policy and procedure in place and people felt any complaints they may need to make would be taken seriously. However, complaints had not always been responded to within the providers own timescales.

Not all the records relating to the delivery of peoples care and the management of the service were up to date, accurate and complete. Therefore, the provider was not able to monitor these areas of practice to ensure that the care delivered was effective.

The providers’ quality assurance processes had not been consistently applied and shortfalls identified as part of this process had not always been rectified within the timescales the provider had set.

At the last inspection in January 2015 not all staff had received training on the Mental Capacity Act 2005 (MCA) and mental capacity assessments were not consistently recorded in line with legal requirements. We also identified that care plans were not regularly reviewed and the provider had no mechanism in place to assess the effectiveness of care plans. These were areas of practice we identified that needed to improve. At this inspection we found improvements had been made and these issues had been addressed.

People’s care plans outlined their needs and the support required to meet those needs. Care plans were personalised and included information on people’s individual likes, dislikes, daily routine and what was important to them. One person’s visitors told us “We are very happy, very pleased they are here, we think they’re safe and that gives us peace of mine”.

People had the opportunity to take part in activities they enjoyed and were meaningful to them. Staff regularly took people out to local shops, cafes and for walks. People’s religious and cultural needs were maintained and supported, and the home had built links with the local church community.

People were treated with respect and dignity by staff. They were spoken with and supported in a sensitive, respectful and caring manner. One person told us “The staff are lovely, they ar

Our inspection team was made up of one Adult Social Care inspector and a specialist advisor in mental health. We answered our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

To obtain the views of people living at Carlton House, we used various methods. We observed staff interactions, delivery of care, speaking to people, staff and relatives. We spoke with five members of staff, the registered manager and a visiting relative.

Below is a summary of what we found. The summary describes what people who used the service and the staff told us, what we observed and the records we looked at. If you want to see the evidence supporting our summary please read the full report.

Is it safe?

Risks to people were assessed, however, care plans and risk assessments did not record the strategies or steps required to provide safe care. Staff could clearly tell us how they supported people living at Carlton House; however, this information was not reflected in people’s individual care plans or risk assessments. We have asked the provider to take action.

Training was provided to staff on the Mental Capacity Act (MCA) 2005. However, the staffs understanding of the legislation and how to undertake a mental capacity assessment was basic. Mental capacity assessments were not completed in line with legal requirements. We have asked the provider to take action.

In March 2014, changes were made to the legislation Deprivation of Liberty Safeguards. If a person is now unable to leave and subject to continuous control and supervision, they maybe under a deprivation of liberty safeguard. Carlton House had not identified who may subject to deprivation of safeguard nor had they taken action to safeguard people. We have asked the provider to take action.

The premises were safe and well maintained. We saw that staff had regularly tested safety equipment such as fire alarms. Floors and carpets were in good condition, which minimised the risk of people tripping.

Is it effective?

People's health and wellbeing was monitored and, where required, referrals to healthcare professionals were made. Feedback was regularly obtained from healthcare professionals. The feedback was positive and healthcare professionals spoke highly of the care provided at Carlton House.

Staff had a clear understanding of the care needs of the people living at the home. Staff had clearly developed good rapport with people. Staff were clearly able to tell the inspection team how they provided care and support to people.

Is it caring?

People were supported to maintain their physical appearance. Where required, people were wearing hearing aids, glasses and study footwear. People had their hair neatly done and women had their jewellery on as they so wished.

People were encouraged to bring furniture and items of importance. Bedrooms were personalised to the individual. Each floor of the home was painted a different colour to help orientate people. The inspection team noted that people had their picture on their bedroom door. The picture was how the person recognised themselves. This also helped people to orientate themselves and freely move around the home.

Is it responsive?

There was a complaints policy and procedure in place, if people or their representatives were unhappy about the home. Complaints were handled appropriately and in a timely manner.

Where people's health had rapidly deteriorated we saw that the service took appropriate action.

Resident and staff meetings were held to explore how positive changes could be made.

Is it well-led?

Incident, accidents and falls were recorded and monitored. However, the home did not have a robust system in place to analyse or investigate emerging themes and trends. We have asked the provider to take action.

Carlton house had a business continuity policy in place. This made sure that the home had a plan in place to deal with foreseeable emergencies. This would reduce the risk of people's care being affected in the event of an emergency such as flooding or a fire.

During our visit to Carlton House there were 22 people using the service. The home was clean, tidy and welcoming. We used a number of different methods to help us understand the views and experiences of people. We spoke with four people who used the service and four relatives.

We observed care being provided and we looked at supporting documentation. We saw that care was delivered in line with people’s individual care plan and as part of a process of assessment, planning and review.

We spoke with the manager and two staff members individually and we spoke with other staff as they were carrying out the duties of their role. We saw that effective recruitment processes were in place and we were told that workers felt supported in their roles. One staff member told us “It’s a happy home.” Another, that the home is “really nice, homely and friendly with a lot of management support.”

People we spoke with told us they were happy with the care they received. One person said “Staff are good. I like it here.” A relative told us “I am very happy with the care. Carers are absolutely first class.”

There were 18 people who used the service at the time of our inspection. We used a number of different methods to help us understand their views and experiences. We talked to two people who used the service and two relatives. We observed the care provided and looked at supporting documentation. We spoke with four members of care staff and the manager. Records showed that people's care needs had been assessed, planned, reviewed and delivered in line with their individual care plan. The service was clean and hygienic and there were effective systems in place to reduce the risk and spread of infection. People’s medication was managed safely. The staff were well trained and demonstrated a good knowledge of people's needs. People who used the service said that staff provided them with all the support and assistance that they needed and wanted. We observed that staff were available when people needed them, they were friendly and supportive. People told us that staff did not rush them and had time to chat with them. This was clearly important to them. People told us that they felt safe and happy living at the service and they did not have any concerns.

Due to the needs of people living at the home we were unable to hold in depth discussions with them. However we did to talk to them briefly, interact with them and spend time observing the care being given to them. We also observed the way staff interacted with people who live at the home.

Those we did speak with said they were happy with the care that they received and the way it was provided.

We inspected Carlton House on the 27 and 28 January 2015. Carlton House is a residential care home that provides care and support for up to 25 older people. On the days of the inspection, 21 people were living at the home. Carlton House provides support for people living with varying stages of dementia along with healthcare needs such as diabetes, Parkinson’s and sensory impairment. The age range of people living at the home varied from 60 – 100 years old.

Accommodation was provided over four floors with a lift and stair lift connecting all floors. Thought and consideration had been given to the environment of the home, making it as dementia friendly as possible. People spoke highly of the home and visiting relatives confirmed they felt confident leaving their loved ones in the care of Carlton House.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission 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 and associated Regulations about how the service is run.

At the last inspection in September 2014, we asked the provider to take action to make improvements on their understanding of the Mental Capacity Act 2005 (MCA), quality assurance of the home and record keeping. An action plan was received from the provider which stated they would meet the legal requirements by 1 January 2015. At this inspection we found improvements had been made, but further areas for improvement were still identified.

Staff understood the principles of consent to care and treatment and respected people’s right to refuse consent. However, not all staff had received training on the Mental Capacity Act 2005 (MCA) and mental capacity assessments were not consistently recorded in line with legal requirements. We have identified this as an area of practice that requires improvement.

Quality assurance systems were not in place to analyse incidents and accidents for any emerging trends, themes or patterns. Care plans were not regularly reviewed and the provider had no mechanism in place to assess the effectiveness of care plans. Despite concerns with the provider’s quality assurance framework, people received care that met their needs in a personal and individual manner. However, we have identified the above as an area of practice that requires improvement.

People felt safe living at Carlton House. Training schedules confirmed staff members had received training in safeguarding adults at risk. Staff knew how to identify if people were at risk of abuse or harm and knew what to do to ensure they were protected.

People were cared for, or supported by, sufficient numbers of suitably qualified and experienced staff. Robust recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work.

Each person had a care plan that outlined their needs and the support required to meet those needs. Care plans were personalised and included information on people’s individual likes, dislikes, daily routine and what was important to them.

People received care that centred on them as an individual and staff were responsive to people’s changing needs. Activities were meaningful to people and promoted their identity and self-worth. Staff regularly took people out to local shops, cafes and for walks. People’s religious and cultural needs were maintained and supported, and the home had built links with the local church community.

Staff received on-going training and support that enabled them to provide effective care. Staff spoke positively of the registered manager and demonstrated a commitment to providing high quality dementia care.

People were treated with respect and dignity by staff. They were spoken with and supported in a sensitive, respectful and caring manner. People were seen laughing and smiling with staff. Staff understood the importance of monitoring people’s health and well-being on a daily basis.

Feedback was regularly sought from people, relatives and healthcare professionals. The registered manager and staff continually strived to make improvements and deliver care that was personal to each person.