Carlton Hall Residential Home and Village received a Good rating across all five key questions in its first inspection under a new provider, with strengths in person-centred care, medicines management, infection control and governance. Minor concerns noted included the absence of a registered manager at the time of inspection, a gap in duty of candour notification to one relative, and a recommendation to strengthen the stair risk assessment.
Concerns (4)
moderate
Governance
: “At the time of our inspection there was not a registered manager in post. The previous registered manager...voluntarily cancelled their registration which was processed on 28 May 2022.”
minorIncident learning: “We received information from one relative about an incident which they had not been made aware of.”
minorComplaints handling: “We received feedback that a relative had not had a response, this was immediately addressed by the manager when we told them.”
minorCare planning: “We recommend the risk assessment relating to the stairs be reviewed and consider how to reduce risks if a person accidently went up the stairs and then fell.”
Strengths
· People felt safe and staff were visible, available and responded to call bells and requests for assistance in a timely way.
· Medicines were administered safely with regular audits, staff training and competency assessments in place.
· Robust infection prevention and control measures were in place, with appropriate use of PPE.
· Staff were described as kind, caring and respectful, with strong person-centred values observed during inspection.
· People's nutritional needs were well met with personalised support, choice and flexible alternatives to the menu.
Quality-Statement breakdown (26)
safe: Assessing risk, safety monitoring and managementGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Adapting service, design, decoration to meet people's needsGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving careGood