We inspected Carleton Court Residential Home Limited on 11 and 26 April 2018. The first day was unannounced and we told the registered provider we would be visiting on the second day.

The service is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service can accommodate up to 24 older people, some of whom may be living with dementia in an adapted building. When we visited 18 people were using the service.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The service was rated Requires Improvement when we last inspected in January 2017. Improvements have been made and the service has been rated Good at this inspection. The registered manager was new in post when we last inspected. At that time they displayed a positive attitude and vision around how they were going to implement change to ensure people received high quality, person centred care. They have worked alongside the provider to develop the staff team, improve morale and the standard of care people received.

We saw they had implemented a new care plan system which ensured people’s preferences were recorded alongside clear information for staff to follow to reduce the likelihood of harm to people.

The provider, registered manager and a consultant auditor had monitored progress and reviewed the service to ensure progress was made. They all understood the on-going changes still required to ensure continuous improvement.

The provider and registered manager used feedback they received from people, relatives and staff to understand how they could improve the service. The registered manager and staff understood the signs of abuse and how to safeguard people appropriately.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible, the policies and systems in the service supported this practice.

People and their families told us they were supported by kind and caring staff. They said their independence was supported and their care was provided in a dignified way. They felt confident to raise concerns if required. People received a person centred service.

Everyone enjoyed the activities on offer but felt they would benefit from more opportunities. There was enough staff on shift to keep people safe and support their care needs. More staff were required to develop the range and frequency of activities on offer. The provider agreed to increase staffing for this purpose following the inspection.

People enjoyed a good varied diet and were involved in choosing the menu on offer. Their nutrition was monitored and health professionals were involved to support people to maintain their health.

People and their families told us they felt safe and well cared for.

We saw safety was well managed including medicines, safe recruitment, the environment and equipment. Significant improvements had been made to the environment and cleanliness of the service.

Staff told us they felt very well supported and they had received enough training to enable them to fulfil their role. The registered manager had a plan to develop the formal supervision and appraisal system in the future.

This inspection started on 25 January 2017. Day one of the inspection was unannounced. We visited on a further two dates: 22 February and 3 March 2017. We told the provider we would be visiting on these dates.

The service was last inspected in February 2016 and was rated requires improvement. We found the registered provider had breached four regulations associated with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to lack of staff, poor cleanliness of the premises and equipment and lack of maintenance. In addition to this, we found shortfalls in the formal assessment of quality and safety by the registered provider and failure to protect people by not doing all that was reasonably practicable to mitigate risk.

We saw improvements had been made in all areas at this inspection. The registered provider had worked with consultants to assess the quality of the service and improve. This had led to the employment of a new manager whom we received positive feedback about from people, their relatives, staff and visiting professionals. We saw the registered provider was committed to making further improvements and we were confident this would happen. We gave time in between the dates of inspection to support the registered to manager to allow for the manager to be inducted and support the inspection process.

Carleton Court is a large property which offers numerous communal lounges for people to spend time in. The service is close to the market town of Skipton. The service provides accommodation for up to 24 people who required support with personal care, some of whom may be living with dementia. At the time of the inspection 22 people lived in the service.

The home had a newly recruited manager who had started the process to become registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We recommended the registered provider reviewed their policies to ensure they reflected current best practice/ law to ensure quality and safety. This would mean staff had the guidance to carry out their role effectively.

People told us they felt rushed, that this meant they did not always experience positive care and that staff did not have time to spend with them. A new dependency tool had been used to determine the staffing levels required to meet people’s needs. This had led to the registered provider assessing the housekeeping staff role and focusing more on effective deployment of staff. On day three of the inspection we observed improvements had been made. The registered provider was committed to improving the experience of people who used the service.

We found recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work. The full work history of applicants had not been documented and the registered provider told us they would improve the system following the inspection.

The care plan system was being developed by the registered provider and manager. The new system aimed to assess risk using recognised tools and ensure all control measures were referenced in care plans for staff to follow. Person centred detail on how a person liked to be supported would continue to be included. We saw people and their relatives were involved in developing their care plan

People enjoyed the activities on offer but had asked that more be available and that their individual hobbies and interests were taken into account more. The registered provider had started to implement new initiatives to support this.

Staff had a basic understanding of the requirements of the Mental Capacity Act (2005) and worked to ensure they supported people to make their own

When we inspected this service in October 2014 we identified three regulatory breaches and rated the service as requires improvement overall. The breaches identified related to staffing, premises and equipment.

We undertook a focused inspection in June 2015 to check that the registered provider had followed their plan and to confirm that they now met with the legal requirements. We found the provider was no longer in breach of regulations and had made significant improvement to the service and the care people received. However, in order for this service to be rated as good we needed to see consistent good practice over time, therefore we would return and review these areas again at the next inspection.

This inspection took place on 29 February and 31 March 2016 and was unannounced. This inspection was a re-rating inspection carried out to provide a new rating for the service under the Care Act 2014 and to see if the registered provider and registered manager had made the improvements we required during our last inspection.

At this inspection the provider had failed to ensure the provision of safe care and treatment for people using the service. This was a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

They had failed to ensure that the premises were clean, safe and well maintained. This was a breach of regulation 15 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

They had failed to ensure that there were sufficient staff to support people living at the service. This was a breach of regulation 18 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

It was clear that the provider had failed to establish and operate systems and processes which would ensure and demonstrate their good governance of the service. We found that the standards of governance and leadership at the home were poor and ineffective. This was a breach of regulation 17(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we have asked the provider to take at the back of the full version of this report.

Carleton Court provides accommodation and care for up to 24 older people. Nursing care is not provided. At the time of this inspection the service was providing care for 23 people.

The home employed a registered manager who has worked at the home for over four years. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The service was not safe. Although some people living at the home told us they felt safe they described staff shortages and having to wait to be attended to. We found people went long periods in communal areas where they were unsupervised and had to rely on each other for assistance.

We observed that care staff were consistently busy with care and non-care tasks such as laundry and food preparation.

Prescribed creams for topical application were not dated on opening and were not discarded every month. This posed a risk of people being treated with medicines which may no longer be effective. People’s needs were regularly assessed, monitored and reviewed, but we found examples where action was not taken to make sure care delivery met people’s individual needs. Risk assessments were completed but risks to people were not always minimised due to the lack of staff at the service.

People had good access to health care services and the service was committed to working in partnership with healthcare professionals. However, these professionals raised concerns with us relating to staffing levels and care delivery.

Satisfactory recruitment and selection procedures were in place and appropria

We carried out an unannounced comprehensive inspection of this service on 21 October 2014. We found a number of breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These correspond to breaches of the new regulations of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 identified below. These were in relation to:

Regulation 18 (Staffing) because the provider had failed to maintain appropriate staffing levels at the home. Regulation 15 (Premises and equipment) because the provider failed to maintain appropriate standards of cleanliness and adequate maintenance of the environment within the home.

After the comprehensive inspection, the provider wrote to us with an action plan to say what they would do to meet legal requirements in relation to the breaches.

We undertook this focused inspection on 10 June 2015, to check that the provider had followed their plan and to confirm that they now met with the legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Carleton Court Home on our website at www.cqc.org.uk

Carleton Court provides accommodation and care for up to 24 people who require nursing or personal care. The home is a converted manor house and accommodation is provided over two floors; the first floor is accessed by a lift and a staircase. There is disabled access to the home, which is set in its own grounds, with parking available. Carleton Court is close to the centre of Skipton.

The home employs a registered manager who has worked at the home for nearly three years. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found that the provider had taken steps to improve the levels of staff working at the home. New members of staff had been recruited by the registered manager. We saw there were enough, qualified, skilled and experienced staff to care for people well. This meant that staff had the time to interact appropriately with people using the service or ensure that they were appropriately supervised and supported.

The systems for staff to follow to minimise the risk of infection had improved. Although we found most areas in the home to be clean we found there were offensive odours present in two areas of the home. We have asked the provider to address these issues.

Areas within the home’s environment had improved with communal areas being re-decorated. New flooring had been fitted in most of the communal areas, these also included areas where the floor covering had been damaged. Damaged furnishings had been removed and new furnishings had been purchased. For example all of the dining room furniture had been replaced with new furniture.

This was an unannounced inspection carried out on the 21 October 2014. At the last inspection in June 2013 we found the provider was meeting the regulations we looked at.

Carleton Court provides accommodation and care for up to 24 people who require nursing or personal care. The home is a converted manor house and accommodation is provided over two floors; the first floor is accessed by a lift and a staircase. There is disabled access to the home, which is set in its own grounds, with parking available. Carleton Court is close to the centre of Skipton.

The home employs a registered manager who has worked at the home for nearly three years. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

We found that there were not enough, qualified, skilled and experienced staff to care for people well. This meant that staff did not have time to interact appropriately with people using the service or ensure that they were appropriately supervised and supported. This is a breach of Regulation 22 (Staffing), of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

The recruitment processes followed by the home when employing staff were robust, which meant that people were kept safe and that staff were suitable to work with vulnerable people.

People told us they felt safe in the home and we saw there were some systems and processes in place to protect people from the risk of harm. However we saw that regular checks to ensure that safety equipment such as the fire alarm system were in good working order was not being carried out.

People received their prescribed medication when they needed it and appropriate arrangements were in place for the storage and disposal of medicines. However this did not include regular auditing by the home, therefore the service could not be confident that medication was being given safely.

There were poor systems for staff to follow to minimise the risk of infection. We found that some areas of the home were unclean as there were offensive odours present. This meant that people could be put at potential risk from infection. Areas within the home’s environment were poorly maintained and required work. Most of the communal areas were in need of re-decorating. In some areas we saw floor coverings were damaged. Furnishings in areas for example the sun room were damaged with some furniture not fit for purpose This is a breach of Regulation 15 (Safety and suitability of premises), of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

People who lacked capacity were protected under the Mental Capacity Act 2005 as the provider was meeting the requirements of the Deprivation of Liberty Safeguards. While no applications had been submitted, appropriate policies and procedures were in place. Staff had received training to understand and ensure safeguards would be put in place to help to protect people.

Staff had completed all mandatory training and had received supervision and annual appraisals.

People’s physical health was monitored as required. This included the monitoring of people’s health conditions and symptoms so appropriate referrals to health professionals could be made.

People’s needs were assessed and care and support was planned and delivered in line with their individual care needs. Care plans contained a good level of information setting out exactly how each person should be supported to ensure their needs were met. Care and support was tailored to meet people’s individual needs and staff knew people well. The care plans included risk assessments. Staff had positive relationships with the people living at the home. The atmosphere was busy with staff having little or no time to spend with people either individually or jointly in the communal areas of the home. People living at the home also told us that staff did not have the time to engage with them and didn’t always respect their privacy.

We observed interactions between staff and people living in the home. Staff were respectful to people when they were supporting them. However, at times interactions and communication between people living at the home and members of staff were poor. For example, mealtimes were not a pleasurable experience for people who required support with their meals due, to the poor practice used by staff. We saw people’s privacy and dignity was not always respected by staff, as we observed staff not knocking on people’s doors before entering their rooms.

There was no programme of activity that was stimulating and meaningful for people living at the home. People told us that there was a lack of activities at the home to keep them occupied. Therefore people did not have access to proper and appropriate activities.

No complaints had been received by the home since the last inspection. Notifications had been reported to the Care Quality Commission as required by law. There were not always effective systems in place to monitor and improve the quality of the service provided. Staff did not always meet as a team where they had the opportunity to discuss their practice. Although staff were supported individually to raise concerns and make suggestions when they felt there could be improvements.

We contacted other agencies such as the local authority commissioners and Healthwatch to ask for their views and to ask if they had any concerns about the home. Feedback from Healthwatch was there no concerns raised about this service. The local authority commissioners had concerns relating to the cleanliness of the home, with odours in some areas. They also had concerns about damaged furniture being used and a shortage of staff. Commissioners had no concerns around care as people looked well cared for when they visited. Although they did have concerns around people’s care plans which had not been reviewed i.e. continuity re instructions from a GP re antibiotics for one person had not been documented.

We used a number of methods to help us understand the experiences of people using the service. This included talking to visitors, staff and observing the care provided. We also spent time talking with people. One person said, "Care here is excellent. I have been involved in decisions about my care and treatment." We observed staff being friendly and warm towards people. We spoke with three visitors who were satisfied with the care and support that was provided in the home.

Before people received any care or treatment they were routinely asked for their consent.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage the administration of medicines safely.

We spoke with four members of staff, who were able to demonstrate a good understanding of the needs of the people who lived at Carleton Court. They told us that they were well supported by the manager and that there were good opportunities for training. However, staff supervision was not always given in a timely way.

There was an effective complaints system available. At the time of our visit there were no outstanding complaints.

The name of one of the managers, Catherine Boocock, appears in this report who was not in post or managing the regulatory activities at this home at the time of the visit. However, their name appears because they were still a manager on our register at the time. (We have now updated our register.)

We spoke with eleven people who use the service, a relative, three members of staff and the manager. One person, who had lived in Carleton Court for a number of years, told us; "I have been very happy here.” People told us that if they required assistance the call bell was always answered quickly by the care staff. The relative said; "Everybody here is wonderful, I can't speak too highly of them."

People told us that they were involved in decisions about their care and how it was given. They told us that they could have a bath when they wanted one and they could choose what to wear. They could also change their mind and this was respected. One resident said they had ’lovely towels, good soap, a comfy clean bed and great home-made food.’ They went on to say that they ‘couldn’t ask for more.’ Another person told us; “The people who look after me always have a smile on their faces and are very willing to help.”

People we spoke with told us that they were helped to seek medical support when they needed it, for example a doctor would be called if they were ill, or district nurses came to treat them. Three people we spoke with said they thought that the care staff and the district nurses worked well together.

One person told us; "I know who to complain to, if ever I need to." People we spoke with said they were clear about how and who to report any concerns about their safety to. The people we spoke with said they ‘felt safe’ in their home, Carleton Court. One person said they thought staff 'protected' them.

People who live at the home told us the home was comfortable and they had everything they needed in their own rooms.

They also told us the food was good and they were always offered a choice from the menu. They said that the staff were very kind and helpful and confirmed that they were always available if needed.