Carlton Hall Residential Home and Village

Updated 27 July 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place in the residential care home. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Two inspectors undertook the site visit on 15 June 2022 and one inspector on 20 June 2022.

Service and service type

Carlton Hall Residential Home and Village is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Carlton Hall Residential Home and Village is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Carlton Hall Residential Home and Village is also a domiciliary care agency. It provides personal care to people living in their own bungalows.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was not a registered manager in post. The previous registered manager, who is also a director of the organisation, voluntarily cancelled their registration which was processed on 28 May 2022. There was a new manager who had submitted a registered manager application to CQC.

Notice of inspection

This inspection was unannounced for the site visit of 15 June 2022. We announced our visit of 20 June 2022, to allow for the service to arrange for us to receive feedback from the people who used the domiciliary care service.

What we did before the inspection

The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We reviewed information we had received about the service since registration, including from staff and members of the public, including relatives. We sought feedback from the local authority and professionals who work with the service. We used all this information to plan our inspection.

During the inspection

During our inspection visits, we spoke with 11 people who used the service in the residential care home and six relatives who were visiting their family members. We observed the interactions between staff and people using the service. With their permission, we visited and spoke with three people who used the domiciliary care service in their own homes and reviewed their care records.

We spoke with the manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also spoke with 13 staff including two deputy managers, the domiciliary service manager, care, reception, catering, domestic and activity staff. We reviewed records relating to the governance and oversight of the service, including audits and health and safety records. We also reviewed records relating to medicines administration, four staff recruitment files, complaints, safeguarding, governance and activities. We looked around the residential care home to check on safety of the environment and infection control processes.

We asked the manager to

Updated 27 July 2022

About the service

Carlton Hall Residential Home and Village is a residential care home and domiciliary care service providing personal care for up 86 people in the residential care home and for people living in their own bungalows on site.

The residential care home was in one adapted building, with four units. The units were Main Hall, Granary, Orangery and Courtyard. At the time of our inspection there were 74 people receiving care and support in the residential care home, some people were living with dementia.

For the domiciliary care service, not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided. There were 15 people using the personal care service at the time of our inspection.

People’s experience of using this service and what we found

There were systems in place to reduce the risk of abuse and avoidable harm. People received their medicines when they needed them, and monitoring systems supported the management team to identify any risks and address them. There were systems in place to learn lessons when, for example incidents happened, to reduce the risk of them happening again.

The environment was suitable and accessible to people who used the service. There were infection control systems in place to reduce risks of cross infection, and staff wore personal protective equipment (PPE) where required. Policies, procedures and risk assessments were in place in relation to infection control and the pandemic. People were supported to have visits from their family and friends.

Staffing levels were kept under review and recruitment was ongoing to reduce the risks of people not receiving the care they needed. Staff recruitment was undertaken safely. People were supported by staff who were trained and supported to meet their needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Prior to using the service, people’s needs were assessed. These assessments were used to develop care plans and risk assessments for people which identified how their needs were met and risks reduced. There was a range of meaningful social activity provided to reduce the risks of boredom and isolation.

People were supported to access health professionals where required and staff worked with health professionals to achieve good outcomes for people. People received a choice of food and drink to reduce the risks of malnutrition and dehydration.

There was a complaints procedure in place and complaints were addressed and used to drive improvement. Governance systems, including audits, supported the management team to monitor the service provided and independently identify shortfalls and address them promptly.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for the service under the previous provider was good, published on 29 December 2018. This service was registered with us on 6 September 2021 under a new provider and location name and this is the first inspection.

Why we inspected

Under the new provider name, this service had not yet been inspected and received a rating. Therefore, we undertook this comprehensive inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection under the previous provider, by selecting the ‘all reports’ link for Carlton Hall Residential Home on our website at www.cqc.org.uk.

Recommendations

We have recommended that the provider develop their existing risk assessment for the stairs in the residential care home, to identify that people may accidentally try to climb the stairs and may fall, and to assess how this risk can be mitigated. See the Safe section of this report.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.