Caroline House

Updated 21 March 2023

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team consisted of two inspectors.

Service and service type

Caroline House is a care home. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Caroline House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed the information we held about the service and the service provider. We looked at notifications and any safeguarding alerts we had received for this service. We sought feedback from the local authority and professionals who work with the service. Notifications are information about important events the service is required to send us by law.

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

During the inspection

We looked around the service and met with the people who lived there. We spoke with eight people to understand their views and experiences of the service and we observed how staff supported people. We also used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with the registered manager, and seven further staff members.

We reviewed the care records of five people and a range of other documents. For example, medicine records, staff training records and records relating to the management of the service. We also looked at staff rotas, and records relating to health and safety.

We continued to seek clarification from the provider to validate evidence found. We spoke with one relative, two social workers and two health care professionals on the 8 March 2023 to complete the inspection.

Updated 21 March 2023

About the service

Caroline House is a residential care service that provides support for upto 28 older people living with dementia, mental health needs and sensory impairment. Accommodation was arranged over two floors with stairs and a lift connecting each level. There were 21 people living at the home at the time of the inspection. Two people were currently in hospital.

People’s experience of using this service and what we found

There were governance systems being used to consistently drive improvement within the service. However were areas that needed to be further developed to ensure people's safety and well-being. For example, there was a lack of clear and accurate record keeping regarding some people's hydration support. Environmental audits had not identified two radiators that were hot to touch and not covered, and whilst accidents and incidents were recorded and analysed, preventative measures to prevent a re-occurrence were not documented to guide staff.

People received safe care and support by staff trained to recognise signs of abuse or risk and understood what to do to safely support people. People had care plans and risk assessments which meant people’s safety and well-being was promoted and protected. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Medicines were given safely to people by appropriately trained staff, who had been assessed as competent. The home was clean, well-maintained and comfortable. There were enough staff to meet people's needs. Safe recruitment practices had been followed before staff started working at the service. Accidents and incidents were recorded and lessons learnt from complaints and incidents were recorded.

The home had an effective management structure which provided good leadership for staff and communicated effectively with people, relatives and professionals. Families, visitors and staff were positive about the management and care team, saying they were approachable and welcoming. Staff were positive about their roles and felt valued for the work they did.

The views of people who lived at the home, their relatives and staff were encouraged and acted upon by the management team. People and their relatives felt able to raise any concerns they had and were confident these would receive an appropriate response.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection.

The last rating for this service was Good (published 22 March 2018)

Why we inspected

This inspection was prompted by a review of the information we held about this service and the age of the last rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We have found evidence that the provider needs to make improvements. Please see the well-led section of this full report.

The provider took immediate action to mitigate risk to people during the inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Caroline House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.