At our last inspection in November 2016 we rated the service overall as Requires Improvement. This was because we found breaches in Regulations 9, 12 and 14 of the Health and Social Care (Regulated Activities) Regulations 2014. This was because medicines were not consistently managed safely, people’s nutrition and hydration needs were not consistently met and care plans did not always accurately reflect people’s needs and their involvement in developing them.

Following the inspection we told the provider to send us an action plan detailing how they would ensure they met the requirements of those regulations. At this inspection we saw the provider had taken action as identified in their action plan and improvements had been made. In addition they had sustained previous good practice. As a result of this inspection the service has an overall rating of Good.

Why the service is rated Good.

Even though the new manager had been in post for a short period of time their appointment had already significantly helped improve the service. Their previous experience and support from their managers had equipped them with the skills and knowledge required for their roles and responsibilities. It was evident they were confident and committed to embrace new challenges and to continue to improve the service. An increase in the provider’s oversight meant that a significant number of improvements had been made to help ensure that people were safe and received good quality care.

Improvements had been made to help ensure people were protected from the risk of poor management of medicines. The manager and staff followed procedures which reduced the risk of people being harmed. Staff understood what constituted abuse and what action they should take if they suspected this had occurred. Staff had considered actual and potential risks to people, plans were in place about how to manage, monitor and review these. People were supported by the service’s recruitment policy and practices to help ensure that staff were suitable. The manager and staff were able to demonstrate there were sufficient numbers of staff with a combined skill mix on each shift.

Staff had the knowledge and skills they needed to carry out their roles effectively. They felt supported by the manager and deputy at all times. The manager and deputy had a good understanding of the Mental Capacity Act 2005 (MCA). The care staff understood its principles and the importance of supporting people to make decisions and protect their rights. People enjoyed a healthy balanced diet based on personal preferences. Systems had improved to ensure food and fluid intake was monitored and recorded effectively.

People and their relatives felt staff were caring and kind. Staff had a good awareness of individuals' needs and treated people in a warm and respectful manner. Care plans had improved and demonstrated that people were involved about how they wished to be supported. The manager, deputy and staff were knowledgeable about people's lives before they started using the service. Every effort was made to enhance this knowledge so that their life experiences remained meaningful.

People benefitted from a service that was well led. People who used the service felt able to make requests and express their opinions and views. Staff were embracing new initiatives with the support of the manager and provider. They continued to look at the needs of people who used the service and ways to improve these so that people felt able to make positive changes.

The provider and manager had implemented a programme of improvement that was being well managed. The manager and provider demonstrated a good understanding of the importance of effective quality assurance systems. There were processes in place to monitor quality and understand the experiences of people who used the service.

This inspection took place on 29 November 2016 and was unannounced. The last full inspection took place in November 2015 and, at that time, two breaches of the Health and Social Care (Regulated Activities) Regulations 2014 were found in relation to need for consent, person centred care and good governance. These breaches were followed up as part of our inspection.

Carlton Mansions is registered to provide accommodation and personal care for up to 26 people. At the time of our inspection there were 24 people living in the home.

There was no registered manager in place on the day of our inspection. 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 2008 and associated Regulations about how the service is run. The current manager’s application is currently being processed.

At our last two inspections we found that the care plans were not sufficiently detailed to help staff provide personalised care based on current needs. Insufficient improvements had been made. This area of their work requires further development.

Medicines were not consistently managed safely. Topical medicine charts were in place, but they had not in all cases been consistently signed by staff to indicate that people had their lotions and creams applied as prescribed. One staff member who administered medicines did not have a full understanding about creams and their expiry date. They also didn’t know about the specifics of administering one medicine they had given as part of the morning’s medicines.

People’s nutritional and hydration needs were not consistently met. Some people were having their food and fluid intake monitored because they had been assessed as being at risk of dehydration or malnutrition. There were gaps in some of the food and fluid charts in place and the fluids were not totalled. Where there had been a low intake there was no evidence that the information had been noted and escalated to a senior member of staff.

At our previous two inspections we found that people were not always safe, as there were not always sufficient numbers staff to support their needs. We found that sufficient improvements had been made.

People’s rights were in the main being upheld in line with the Mental Capacity Act (MCA) 2005. This is a legal framework to protect people who are unable to make certain decisions themselves.

A range of checks had been carried out on staff to determine their suitability for work. Staff were supported through an adequate training and supervision programme.

People had access to on-going healthcare services. Records showed when people were reviewed by the GP, district nurse and the dementia well-being team. Referrals for advice and support were made in a timely manner and when people’s needs changed.

People told us that staff were in the main caring and respectful. Comments from people and relatives included, “The staff are all lovely here, they work hard"; “I think they look after everyone as best they can I would recommend it definitely”; “She’s a top lady [care assistant] and she’s as good as gold.”

The provider had systems in place to receive and monitor any complaints that were made. We reviewed the complaints file. Where issues of concern were identified they were taken forward and actioned.

Since the previous inspection the service has appointed a new manager and deputy manager. Staff, people and relatives held them in high regard.

People were encouraged to provide feedback on their experience of the service to monitor the quality of service provided.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

This inspection took place on 9 November 2015 and was unannounced. The last full inspection took place in March 2015 and, at that time, three breaches of the Health and Social Care (Regulated Activities) Regulations 2014 were found in relation to safe care and treatment, staffing and person-centred care. These breaches were followed up as part of our inspection.

Carlton Mansions is registered to provide accommodation and personal care for up to 26 people. At the time of our inspection there were 23 people living in the home.

A registered manager was in post at the time of inspection. 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 2008 and associated Regulations about how the service is run.

In March 2015 we found that staffing levels were not sufficient to meet people’s needs. Some people did not receive personalised care and some people were left for long periods of time without staff interactions. The manager told us that staffing levels were assessed by following the Care Home Equation for Safe Staffing (CHESS) dependency tool. We viewed the staffing level rota over a five-week period from 21/9/15 – 25/10/15. During the day staffing levels were maintained in accordance with the dependency needs of the people who lived at the service. The night time staffing level fell below the level recommended by the CHESS tool on a number of occasions. The provider was not deploying sufficient numbers of staff to ensure they could meet people’s care and treatment needs. The registered manager provided evidence of their current recruitment drive to appoint night time carers.

At our last inspection in March 2015 we found that the people’s care plans were not sufficiently detailed to help staff provide personalised care based on current needs The provider sent us an action plan telling us what they were going to do to become compliant. During the inspection we found some improvements had been made but there were still areas which required further development. Care plans were well written and easy to navigate. They had all been reviewed and audited on a monthly basis. However, they were not consistently person centred. Life stories were not always completed which meant that staff did not always have an understanding of people’s lives before they moved to the service.

The service did not have an activities coordinator in post. By not ensuring that a dedicated activities coordinator was available throughout the day the service did not enable people to carry out activities which encouraged them to maintain hobbies and interests.

In March 2015 we found that infection control guidance was not followed and the home was not suitably clean in all areas. We found that sufficient improvements had been made.

People’s rights were being upheld in line with the Mental Capacity Act 2005. This is a legal framework to protect people who are unable to make certain decisions themselves. We saw information in people’s support plans about mental capacity and Deprivation of Liberty Safeguards (DoLS). DoLS applications had been applied for appropriately. These safeguards aim to protect people living in homes from being inappropriately deprived of their liberty.

A range of checks had been carried out on staff to determine their suitability for the work. Staff were supported through an adequate training and supervision programme. Staff we spoke with demonstrated a good understanding of how to recognise and report suspected abuse.

People had their physical and mental health needs monitored. All care records that we viewed showed people had access to healthcare professionals according to their specific needs.

People and relatives spoke positively about the staff and told us they were caring. One person told us; “There is a warm friendly atmosphere. Staff will sit and talk things through. They are very supportive. We have a laugh together and that’s really important.” Staff told us they aimed to provide personal, individual care to people.

Relatives were welcomed to the service and could visit people at times that were convenient to them. People maintained contact with their family and were therefore not isolated from those people closest to them.

The overall feedback about the service and the manager had been positive. Staff spoke positively about the manager. People were encouraged to provide feedback on their experience of the service and monitor the quality of service provided. One relative commented; “I meet the manager regularly. She visited Mum in hospital when she was poorly. I am confident she is a good manager.”

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

This inspection took place on 31 March 2015 and was unannounced. The previous inspection was carried out on 21 October 2013 and there had been no breaches of legal requirements at that time.

Carlton Mansions is registered to provide accommodation and personal care for up 26 older people. The home provides a service to people who are living with dementia. At the time of our inspection there were 19 people living in the home.

A registered manager was in post at the time of inspection. 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 2008 and associated Regulations about how the service is run.

Staffing levels were not sufficient to meet people’s needs. Some people did not receive personalised care and some people were left for long periods of time without staff interactions.

Infection control guidance was not followed so the home was not suitably clean in all areas. The kitchen was cluttered and areas required deep cleaning to meet appropriate standards in relation to food preparation areas.

Care plans were not always representative of people’s current needs and did not always give detailed guidance for staff to follow. This risked people’s needs not being met.

Correct moving and handling techniques were not always followed. Moving aids were not always used to support people. Therefore people could be at risk of unsafe moving and handling.

Quality and safety in the home was monitored to support the registered manager in identifying any issues of concern. The registered and regional manager undertook regular audits, however not all highlighted the areas of improvement that were required.

Some people were able to tell us of their experience of living in the home and told us they were happy with the service they received. Comments included “I’m ok love” and “it’s nice and warm I’m safe now”.

Staff received training and understood their obligations under the Mental Capacity Act 2005 and how it had an impact on their work. Within people’s support plans we found the service had acted in accordance with legal requirements when decisions had been made where people lacked capacity to make that decision themselves.

Staff had attended Deprivation of Liberty Safeguards training (DoLS). This is legislation to protect people who lack mental capacity and need to have their freedom restricted to keep them safe. Authorisations have been made for all people living in the home. Two people have had them granted and other people are awaiting assessment from the external authorising body.

We found the provider had systems in place that safeguarded people. Some people were unable to tell us if they felt safe due to the level of their dementia. However one person we spoke with told us “I’m ok love. Yes I’m safe here” and people appeared relaxed in the company of staff.

The provider had ensured that staff had the knowledge and skills they needed to carry out their roles effectively. Training was provided and staff we spoke with were knowledgeable about people’s needs. One member of staff told us how they were being supported to undertake further development training that would enhance their role.

Safe procedures and a policy was in place to guide staff to manage people’s medicines safely. People received their medicines in line with their GP instructions.

Activities were provided to people that lived in the home on a regular basis. This included community groups visiting people in the home.

Staff meetings took place on a regular basis. Minutes were taken and any actions required were recorded and acted on. Staff that we spoke with confirmed this.

There were systems in place to obtain the views of people who used the service and their relatives and satisfaction surveys were used.

The provider had systems in place to ensure that people's needs were assessed and care was delivered that was appropriate to their needs, the views of people and their families were taken into consideration and included in their personal plans of care.

People spoke about the staff being "good". Visitors commented on how "the staff were very kind and "welcoming".

Staff spoke about feeling supported by their manager, training needs were identified and regularly reviewed and all new staff received a period of induction.

Our observation showed that people were treated in a manner that was respectful, kind attentive.

People had positive views about life at Carlton Mansions. Examples of comments we were told included, “The manager makes this place so good”. “The place is so homely”. “The staff are all lovely and will do anything for you”. “There is always something to do”. “The food is lovely”. “They will do anything for you”.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. Our observations showed people who used the service were treated in a respectful way by the staff and their needs were being properly met.

We spoke with three people living with dementia who use the service. They told us that staff treated them with respect and supported them in their care. The people we spoke with were not aware that they had a care plan.

People we spoke with told us staff cared for them in a caring and supportive manner. People told us they enjoyed living in the home. One person said "I wouldn't want to be anywhere else". We were also told that people had a choice in their involvement in activities.

We observed that care was provided in a supportive manner. For example, we saw one member of staff reassuring a confused resident about when lunch was and pointed out the time on the clock.

We saw that people were cared for in a caring and supportive manner. We saw staff responding to people's requests for support. We observed the lunchtime meal. We saw staff asked people if they wanted to have their food cut up for them and provided support as necessary. Staff we spoke with demonstrated good knowledge of the needs of the people within the home.

One person, who had recently moved into the home, made a complaint about the lay out of their room. Staff listened to the person's concerns and moved the furniture around in accordance with the person's wishes.

People who use the service told us they feel safe in the home and that the staff were all very caring.