CQC report explained · a nursing home
What the CQC found at Carleen Nursing and Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People said they felt safe. Inspectors found suitable staffing, safeguarding arrangements, risk assessments, medicines systems, infection control and emergency plans.
- Effective?
- Good
- Staff were trained and supported, and people received suitable food, drink and healthcare. Inspectors found that staff understood mental capacity and supported people to make choices.
- Caring?
- Good
- Staff were kind, patient and respectful. People were involved in decisions, their privacy was protected, and they were supported to remain as independent as possible.
- Responsive?
- Good
- Care plans reflected people's preferences and communication needs. People were offered individual and group activities, and complaints were investigated promptly.
- Well-led?
- Good
- Inspectors found clear management roles, strong quality checks and good involvement of people, families and staff. The home worked with health and social care professionals.
What inspectors found, March 2019
Carleen Nursing and Residential Care Home was rated Good; inspectors found safe, kind and well-organised care across all five areas.
This was an unannounced planned inspection on 12 February 2019. Three inspectors and an expert by experience reviewed records, spoke with people, relatives, staff and healthcare professionals, and checked accidents, complaints, training and quality audits.
The inspectors found that people felt safe and were supported by trained staff. Medicines were managed safely, risks were recorded and reviewed, and the home was clean. People received suitable food, healthcare support and help to make their own decisions.
People described staff as kind, patient and respectful. Care plans were detailed and personal. People were offered activities, supported to remain independent, and involved in decisions about their care.
The home received a Good rating for Safe, Effective, Caring, Responsive and Well-led. This means the inspectors found good standards overall at the time of this inspection. It was also rated Good at the previous full inspection, published in November 2016.
Safe care and medicines
Risks were recorded and updated when people's needs changed. Inspectors found that medicines were administered safely and as prescribed.
“Medicines administration records (MAR) were completed correctly and indicated that people received their medicines as prescribed.” from the report
Kind and respectful staff
People and relatives spoke positively about staff. Inspectors observed respectful interactions and found that privacy and dignity were protected.
“Staff were friendly and polite. Interactions between staff and people were natural and showed positive relationships had been developed.” from the report
Personalised care
Care plans described people's preferences, communication needs and the support they required. People and families were involved in reviews.
“Care plans were detailed and person centred. People were involved in deciding how they wished to be supported and in reviewing their care plans when needed.” from the report
Good management checks
The management team used audits and action plans to monitor care, medicines, training, cleaning and the environment. Feedback from people and families was collected and considered.
“There were robust quality assurance procedures, which included audits of care plans, cleaning records, medicine administration and stock, environmental audits, training and food safety.” from the report
Activities and independence
People could take part in individual and group activities and were encouraged to do things for themselves where possible.
“People were provided with opportunities to participate in a range of activities.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you currently assess staffing levels against each person's care and nursing needs?
- 02How will you make sure my relative's medicines, including any creams or time-sensitive medicines, are given safely?
- 03How often will my relative and our family be involved in reviewing the care plan?
- 04What individual and group activities are available for someone with my relative's interests and abilities?
- 05How would you support my relative with end of life wishes and preferred place of care?
This was an unannounced planned comprehensive inspection covering all five CQC questions; the report says the previous full inspection was published on 14 November 2016. This explanation was written from the published report of 15 March 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, November 2016
Carleen Nursing and Residential Care Home was rated Good; inspectors found safe, kind and responsive care, with some records and staffing arrangements still being improved.
Inspectors made an unannounced visit over 19 and 20 October 2016. They spoke with people living at the home, relatives, staff and health and social care professionals. They also observed care and checked care plans, medicines records, staff files, complaints and other management records.
All five areas were rated Good: safe, effective, caring, responsive and well-led. Inspectors found enough staff, safe medicines procedures, good training, respectful care, personalised support and activities. People were supported to make choices and stay as independent as possible.
There were some areas still being improved. Care records were clear but not well organised, some agency staff did not know people as well as permanent staff, and staff roles were not always clear. The manager had started changes to records, staffing and leadership arrangements.
Safe staffing and medicines
Inspectors found enough staff to meet people's needs and safe systems for recruiting staff and managing medicines.
“There was sufficient staff available to meet the needs of people.” from the report
Kind and respectful care
Staff knew people well, listened to them and protected their privacy and dignity. People were supported to remain independent.
“People's privacy and dignity was maintained and staff were caring and considerate as they supported people.” from the report
Food and mealtimes
Meals were freshly prepared and adapted to people's preferences and health needs. The dining area had been changed to create a calmer, more social experience.
“People enjoyed a good dining experience at mealtimes in the home.” from the report
Management checks
The home had audits covering areas such as medicines, infection control, equipment and fire safety. Actions identified through these checks had been completed.
“Robust audits and systems were in place to ensure the safety and welfare of people in the home.” from the report
Agency staff knowledge
needs fixingSome people said agency care staff did not always know their needs as well as permanent staff. One person also felt agency staff could appear rushed.
“Some people told us when agency staff were working at the home they often did not have the same understanding of their needs as the permanent staff.” from the report
Care records were not well organised
needs fixingCare plans contained important information but were sometimes duplicated or inconsistent in format. A new record system had only recently started being introduced.
“Records of the care people required and received held clear information but often lacked clear organisation and format.” from the report
Some staff roles were unclear
minorThe differences between team leader and senior carer roles were not always clear. The manager was working to define responsibilities.
“There was a lack of clarity in the differences between these roles.” from the report
- 01How do you now make sure agency staff understand each person's needs and preferences before starting a shift?
- 02Has the new care-record format been introduced for everyone, and how do you check that records remain accurate and easy to follow?
- 03What are the current responsibilities of team leaders and senior carers?
- 04How do you decide when to contact health and social care professionals, and has the number of unnecessary calls reduced?
- 05What changes have been made since the inspection to the staffing structure and leadership arrangements?
This was an unannounced inspection covering all five CQC questions and the overall quality of the home. This explanation was written from the published report of 12 November 2016 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Carleen Nursing and Residential Care Home
2 rated inspections over 2 years: the service has held its Good rating throughout.
- March 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Carleen Nursing and Residential Care Home →
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Carleen Nursing and Residential Care Home →
- October 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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