CQC report explained · a residential care home
What the CQC found at Charlton House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Controlled drugs were not stored or recorded as required. Emergency evacuation plans and evidence of fire drills were not accessible during the visit, although the provider sent evidence afterwards that these had been completed.
- Effective?
- Good
- People's needs were assessed and care plans reflected their needs. Staff had relevant training and supported people with healthcare, nutrition, communication and decision-making.
- Caring?
- Good
- Staff respected people's choices, privacy, dignity and independence. People and relatives were consulted, although one relative said they had not been involved in assessment and care planning.
- Responsive?
- Requires improvement
- Care plans were personalised and regularly reviewed, and people were supported with communication, family contact and activities. However, some staff had not read the care plans and risk plans before providing care.
- Well-led?
- Requires improvement
- The quality assurance system did not identify or correct the problems found. There was a management structure and staff felt supported, but there was no registered manager in post at the time of inspection.
What inspectors found, July 2022
Rated Requires Improvement; inspectors found good care and support in some areas, but safety, responsiveness and leadership needed improvement.
This was the first inspection of the newly registered home. It supported up to five younger adults with learning disabilities or autism, and two people were living there at the time. The visit was unannounced and took place on 20 June 2022.
Inspectors spoke with people, a relative, care staff and managers. They observed care, checked care records, staff files, medicines records and management systems, and sought further evidence after the visit.
People were generally treated with dignity and supported to make choices. Staff were trained, people had access to healthcare, and the home supported communication, family contact and activities. However, medicines controls, access to emergency evacuation plans, staff knowledge of care plans and quality checks were not always reliable.
The overall rating was Requires Improvement. Effective and Caring were rated Good. Safe, Responsive and Well-led were rated Requires Improvement. The report says there was no evidence that people had been harmed, but weaknesses placed people at risk and the provider must improve its quality assurance.
Kind and respectful care
Staff respected people's choices, privacy and dignity. People were encouraged to remain as independent as possible.
“People were treated with dignity; their privacy was respected and they were supported to be as independent in their care as possible.” from the report
Trained staff
Staff had training linked to people's needs, including safeguarding, medicines, diabetes, fire safety and communication. They also received supervision and could approach the manager for support.
“The provider supported staff through supervision and training to ensure they had the appropriate knowledge and skills to meet people's needs.” from the report
Personalised communication
The home assessed people's communication needs and used objects, photographs, gestures and other individual approaches to help people make choices.
“Staff offered choices tailored to individual people using a communication method appropriate to that person.” from the report
Health and professional support
Staff worked with healthcare professionals and supported people to attend appointments. Care records included health needs and the support required.
“People's health needs were recorded in their care plans along with any support required from staff in relation to these needs.” from the report
Controlled medicines
seriousControlled drugs were not stored separately and the required register was not being used. The manager said this would be corrected, and documents sent after the visit showed action had been taken.
“We saw controlled drugs (CD) were not stored separately, in line with controlled drug requirements but with other prescribed medicine in a lockable cabinet.” from the report
Emergency arrangements
seriousPersonal emergency evacuation plans were not accessible at the home during the inspection, and inspectors could not see evidence of day and night fire drills at that time.
“Each person's personal emergency evacuation plans (PEEP) was not accessible on site, should there be an emergency.” from the report
Staff knowledge of care plans
seriousSome staff had not read the care and risk plans before supporting people with complex needs. This could make it harder to provide consistent and safe care.
“Some staff had not read and understood what was written in the risk management and care plans prior to delivering safe care at all times to people.” from the report
Weak quality checks
seriousThe provider's checks did not identify the medicines, care plan and emergency planning problems found by inspectors. This was a breach of Regulation 17.
“The quality assurance system and processes had failed to identify and correct issues we found at the inspection.” from the report
Family involvement
needs fixingOne relative said they had not been consulted about assessment and care planning because they could not travel a long distance. The manager said they would work to involve them.
“However, one relative told us they were not consulted about the assessment and planning care for their loved one, and they cannot travel long distance to the care home.” from the report
- 01How are controlled drugs now stored, recorded, checked and audited?
- 02Can you show us where each person's personal emergency evacuation plan is kept, and how often fire drills are completed?
- 03How do you make sure every staff member reads and understands each person's care and risk plan before providing support?
- 04What changes have you made to the quality assurance system since this inspection, and how do you know the changes are working?
- 05Has a registered manager now been appointed, and who is responsible for the home until then?
This was the first inspection of the newly registered home and assessed all five CQC key questions, including care and the premises, with two people living there at the time. This explanation was written from the published report of 23 July 2022 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 Charlton House
Each visit the CQC has published, newest first, back to the day the home was registered.
- July 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2021
Registered with the Care Quality Commission on 12 March 2021.
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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