Carlton Court is a domiciliary care agency; at the time of our assessment, they were supporting 18 people with a regulated activity. The assessment took place on the 14 August till 16 August 2024. The assessment was completed to follow up on the last inspection to see if improvements had been made. We found the service had made improvements and are no longer in breach of regulations. Staff now assessed and mitigated risks and care plans now guided safe practice. The registered manager now had systems in place to monitor the service and provide good oversight to monitor and improve outcomes for people.
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Carlton Court, a domiciliary care agency serving approximately 20 people, was rated Requires Improvement following a focused inspection in February 2023, with breaches of Regulation 12 (safe care and treatment) and Regulation 17 (good governance) identified. Key failures included absent person-centred care plans and risk assessments, no system to monitor missed or late calls, lack of medication audit oversight, and ineffective governance systems, while staff safeguarding awareness and infection control practices were noted as strengths.
Concerns (8)
criticalCare planning: “Care plans and risk assessments did not contain enough guidance for staff to mitigate risks and provide safe support to people.”
criticalGovernance: “Governance systems had not been fully implemented. A quality audit carried out by the service identified audits needed updating.”
criticalMedication management: “We could not be assured people were receiving medicines safely as there were no reviews or audits of medication administration records (MARS) available.”
moderateMissed or late visits: “The registered manager had no system in place to monitor late or missed calls and relied on people or their relatives being able to ring them.”
moderateRecord keeping: “Actions from staff meeting minutes were not recorded so there was no evidence issues raised had been addressed.”
moderateStaff competency: “We did not see any evidence of competency assessments and noted five staff were waiting to have medicines training.”
moderatePerson-centred care: “Care plans we reviewed consisted of a list of tasks for staff to complete rather than detailing how people could be supported to have their needs met safely.”
minorOther: “A full employment history had not been obtained in 1 and only 1 reference had been obtained.”
Strengths
· Staff were aware of how to raise safeguarding concerns and worked with the local authority to keep people safe.
· Staff had received training in infection prevention and control and had access to PPE.
· The registered manager understood their duty of candour responsibilities and worked closely with stakeholders to address issues.
· People and relatives were positive about staff, describing them as lovely and caring.
· DBS checks were completed for staff, and internationally recruited staff received a structured induction including shadow shifts.
Quality-Statement breakdown (8)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
well-led: Promoting a positive culture; managers and staff clear about roles; continuous learningRequires improvement
well-led: Duty of candour; working in partnership; engaging people and staffGood
First inspection of Rubicon Court (Mevtec 360) rated Good across all five key questions, with people reporting safe, caring and well-led support. A recommendation was made about exploring end of life care preferences in care plans, alongside minor record-keeping and review-tracking observations.
Concerns (3)
minorEnd-of-life care: “Peoples care plans did not contain evidence that the service explored people's preferences and choices in relation to end of life care.”
minorCare planning: “We found the risk assessment document for recording risks did not include all risks to people as these were sometimes recorded on the persons care plan instead.”
minorGovernance: “the providers records did not always reflect when these were due. For example one persons care plan was last reviewed in June 2019. The service had a policy of monthly care plan reviews.”
Strengths
· Staff were punctual and there were enough staff to meet people's needs
· Safe and effective recruitment practices including DBS and reference checks
· Staff completed required training including safeguarding, MCA and infection control
· Person-centred care plans reviewed monthly with people involved
· Registered manager described as approachable, motivating and supportive
Quality-Statement breakdown (24)
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experience
Not rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies to provide consistent, effective, timely careNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: End of life care and supportNot rated
responsive: Supporting people to develop and maintain relationships to avoid social isolationNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
well-led: Continuous learning and improving careNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Working in partnership with othersNot rated