CQC report explained · a residential care home
What the CQC found at Carleton House Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that infection prevention and control arrangements covered PPE, testing, visiting, hygiene, admissions and outbreak management. They said further work was needed on COVID-19 policies and risk assessments.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Requires improvement
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, May 2021
Inspected but not rated; inspectors found good infection control, but COVID-19 policies and risk assessments needed more work.
This was an announced, targeted inspection on 27 April 2021. It looked at infection prevention and control during the COVID-19 pandemic, rather than the full quality of the home.
Inspectors found that the home was clean and hygienic, had enough personal protective equipment, and staff were using it correctly. Testing was taking place for staff, visitors and people living in the home. Visiting arrangements followed current government guidance.
Inspectors were assured about the home's arrangements for visitors, shielding, social distancing, admissions, PPE, testing, hygiene and managing outbreaks. However, more work was needed on COVID-19 policies and risk assessments. The service was inspected but not rated, so this report does not give an overall quality rating.
Clean environment
The home was clean and hygienic. Cleaning schedules and products had been reviewed during the pandemic.
“The environment was clean and hygienic. Cleaning schedules and products had been reviewed during the pandemic to help support this.” from the report
PPE available and used
There was plenty of PPE, and staff were using it correctly to help prevent infection spreading.
“There was plenty of personal protective equipment (PPE) available. Staff were using this correctly to help prevent the spread of transmission.” from the report
Testing arrangements
Regular COVID-19 testing was taking place for staff, visitors and people living in the home.
“Regular COVID-19 testing of staff, visitors, and people using the service was taking place.” from the report
Visits supported
The home supported people to keep in touch with relatives and friends, following current visiting guidance.
“The service was supporting people to stay in touch with relatives and friends. Current government guidance on visiting was being followed.” from the report
Policies needed review
needs fixingInspectors said the COVID-19-specific policies and risk assessments needed further work to support staff practice. The provider said these would be reviewed.
“Further work was required on the COVID-19 specific policies and risk assessments to help underpin and support staff practice.” from the report
- 01What changes have been made to the COVID-19-specific policies and risk assessments since the inspection?
- 02How often are staff, visitors and people living in the home tested for COVID-19?
- 03How are visits being arranged and how is current visiting guidance being followed?
- 04How do you check that staff are using PPE correctly?
- 05What arrangements are in place to prevent or manage an infection outbreak?
This was a targeted inspection of infection prevention and control during the COVID-19 pandemic; the service was inspected but not rated and the report does not assess the other key questions. This explanation was written from the published report of 26 May 2021 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, February 2020
Carleton House Care Home was rated Good overall; inspectors found kind, person-centred care, but management systems needed improvement.
This was an unannounced inspection on 02 January 2020. Inspectors spoke with people living in the home, relatives, staff and health professionals. They reviewed care, medicine and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found enough staff, safe medicines, good cleanliness, kind staff and care that met people's needs and preferences. People were supported with food, health care, activities and relationships.
Well-led was rated Requires Improvement. Care plans were not always detailed, and there was no formal system to monitor quality across the home. Inspectors said this had not affected the quality of care at the time of the inspection, but recommended that the provider improve its monitoring and governance.
Kind and respectful care
People and relatives described staff as kind, approachable and respectful. Inspectors saw warm interactions and found that staff knew people well.
“Staff cared for people in a kind and caring manner.” from the report
Safe medicines
Medicines records were completed accurately. Audits were used to identify errors and help ensure people received medicines as prescribed.
“Medicines were managed safely and people received their medicines as prescribed.” from the report
Enough, consistent staff
Inspectors found enough staff to meet people's needs. Many staff had worked at the home for a long time, helping them understand people well.
“This meant people benefited from a stable and consistent staff group who knew them well.” from the report
Personalised support
People could choose when to get up and go to bed, take part in activities and follow their hobbies. Staff supported relationships with relatives.
“Whilst improvements were needed in respect to people's written plans we found in practice people received individual and personalised care.” from the report
Quality monitoring
needs fixingThe home did not have a formal system covering quality monitoring or a detailed service development plan. Inspectors recommended getting advice on improving governance.
“There was a lack of a formal quality monitoring systems and processes.” from the report
Care records lacked detail
needs fixingSome care plans did not give staff enough detail about people's wishes, preferences, social history or spiritual needs, including at the end of life.
“These were not always detailed and did not include information about people's preferences, social history, or spiritual needs in relation to their end of life.” from the report
Some staff training was limited
needs fixingAlthough basic training was in place, relatively few staff had completed training in areas such as nutrition and person-centred care. The provider planned to review training, including dementia and end of life care.
“Training records showed other subjects such as nutrition and person-centred care were available but the amount of staff who had undertaken training in these areas was low.” from the report
Unsecured back door
needs fixingInspectors found a back door unsecured. They said this could allow people to leave or enter without staff knowing, and the provider said it would complete a formal risk assessment.
“a back door was left unsecured which posed a risk that people could leave or enter the building without staff knowing.” from the report
- 01What formal quality monitoring system and service development plan have you put in place since this inspection?
- 02How do you now make sure care plans record each person's wishes, preferences, social history and spiritual needs?
- 03What staff training has been completed in dementia, end of life care, nutrition and person-centred care?
- 04What action was taken after the unsecured back door was found, and how is this risk now checked?
- 05How are accidents and incidents analysed for patterns and used to update people's care plans?
This was a planned but unannounced inspection covering all five key questions, with care, premises, records and feedback reviewed; the previous inspection was published on 4 July 2017. This explanation was written from the published report of 1 February 2020 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 Carleton House Care Home
2 rated inspections over 3 years: the service has held its Good rating throughout.
- May 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- February 2020Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016
Registered with the Care Quality Commission on 20 June 2016.
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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13 live-in carers within about an hour of Norfolk
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Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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