We had carried out a comprehensive inspection of this service on 31 July, and 1,3 and 10 August 2018. We issued three breaches of regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to the safety of the medicines management, the robustness of risk assessments for people who used the service and the quality of care planning. Following the inspection, we asked the provider to complete an action plan to show what they would do and by when to meet the regulations.

After the inspection we continued to receive notifications from the provider about medicine errors that had occurred at the service. The relevant local authority safeguarding teams were also appropriately informed by the provider about these medicine errors. In December 2018 we attended a safeguarding meeting at the service in relation to medicine errors for one person who used the service.

This focussed inspection on 10,11 and 15 January 2019 was conducted to check whether the provider had taken suitable and timely action to address the areas identified for improvement at the previous inspection. The first day of the inspection was unannounced and the next two days were announced. This report only covers our findings in relation to this topic. You can read the report from our previous inspection, by selecting the ‘all reports’ link for Carlton Dene on our website at www.cqc.org.uk. We rated the service requires improvement at the previous inspection. At this inspection the service has also been rated requires improvement. This is the fourth consecutive rating of requires improvement for the service.

Carlton Dene is a ‘care home’ that provides personal care and accommodation for older adults. People living at the service require care and support as they are living with dementia and/or are frail due to chronic health difficulties and/or physical disabilities. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during the inspection. Carlton Dene can accommodate up to 42 people and 40 people were living at the service at the time of the inspection. The premises are purpose built and divided into four separate units. People are provided with a single bedroom with en-suite facilities and shared communal areas. The service provides permanent placements and respite care.

At the time of the inspection the registered manager was on maternity leave. 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. The provider informed us they had appointed a peripatetic manager who will cover the rest of the registered manager's maternity leave. The service was being temporarily managed by the regional manager and the deputy manager.

At this inspection we found the provider had failed to ensure that people who used the service safely received their medicines.

Systems were in place to identify risks to people’s safety and wellbeing. Risk assessments were in place and these were updated to reflect changes in people’s needs and circumstances.

Improvements had been made to ensure people who used the service were provided with a safer physical environment. The premises were free from any offensive malodours and appropriate infection control procedures were followed to prevent cross infection.

People told us they felt safe living at the service and relatives expressed that their family members were safely cared for. The provider had liaised with local authority safeguarding teams and changed the way it sent safeguarding notifications, to ensure that information was appropriately received.

Staffing re

This inspection took place on 31 July, 1, 3 and 10 August 2018. The first day was unannounced and the other days were announced. Carlton Dene is a ‘care home’ that provides personal care and accommodation for older adults. People living at the service require care and support as they are living with dementia and/or are frail due to chronic health difficulties and/or physical disabilities. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during the inspection. Carlton Dene can accommodate up to 42 people and 40 people were living at the service at the time of the inspection. The premises are purpose built and divided into four separate units. People are provided with a single bedroom with en-suite facilities and shared communal areas. The service provides permanent placements and respite care.

At our previous inspection we had rated the service as Requires Improvement. Safe, caring and well-led had been rated as Requires Improvement and effective and responsive had been rated as Good. We had issued two breaches of regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to dignity and respect, and good governance. We had also made three recommendations in relation to the use of topical medicines and the medicine fridge temperature checks, determining the correct staffing levels and meeting people’s end of life care needs. Following the previous inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe, caring and well-led to at least Good. At this inspection we found that the provider had met the breaches and recommendations.

At the time of the inspection the registered manager was on maternity leave. 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. The provider informed us that they were in the process of recruiting an interim manager. Temporary management arrangements were in place until an interim manager commenced at the service and completed their induction.

At this inspection we found that improvements had been achieved in relation to the use of topical medicines and medicines were being stored at the correct temperatures, in line with the manufacturers' instructions. We saw that prescribed topical applications were being stored securely in people's bedrooms and staff were correctly completing topical medicine administration records (MARs). We noted that some staff needed guidance to ensure they properly supported people to take their respiratory inhalers, which was discussed with the provider during the inspection. We were aware that there had been medicine errors since the previous inspection and saw that recent improvements had been made to the management of medicines, and actions were in place to support senior care staff to safely administer medicines. At the time of the inspection staff were being closely supported by the regional care development manager but this was a temporary measure and another medicine error occurred during the inspection. Therefore we could not be assured that systems were embedded to ensure the effective governance of medicines.

People told us they felt safe and at ease with staff. Records showed that staff had attended safeguarding adults training and were aware of their responsibilities. Safeguarding notifications were appropriately sent to CQC, in accordance with legislation.

Risk assessments had been developed to identify and mitigate risks to people's safety and wellbeing.People's risk assessments were in the proce

We inspected Carlton Dene Residential Care Home on 12 and 13 June 2017, the inspection was unannounced on the first day and we informed the registered manager we would be returning the following day to complete the inspection. Our last inspection took place on 26 and 27 September 2016 where we found three breaches of regulations relating to safe care and treatment, person centred care and good governance. The provider sent us an action plan following the inspection telling us what they were going to do to improve the service.

Carlton Dene Residential Care Home provides accommodation and respite care for up to 42 older people. There are two floors in the building divided into four units which provide a mixture of respite and permanent placements. The home had communal lounges, dining areas, activity rooms and an open courtyard. At the time of our inspection there were 40 people living at the home.

The service had a registered manager who was present on both days of the inspection. 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.

Safeguarding concerns were reported and the provider took preventative action to minimise further concerns. People told us they felt safe and the registered manager was aware of her responsibility to report allegations of abuse to keep people safe from harm. Risk assessments were in place and updated to show how risks could be managed and reduced, however records were not always fully completed or up to date.

Areas of the home were clean but more detailed checks were needed to monitor the upkeep of this. Health and safety checks of the building took place and emergency evacuation plans were in place.

Incidents and accidents were reported and documented, but further learning was needed from the outcome of these to mitigate the risk of people receiving unsafe care.

The application of topical creams was not managed safely. Medicines had been administered as prescribed and disposed of safely but monitoring of fridge temperatures for the storage of medicines required further improvements. Staff had received regular medicines training and their competency to manage medicines had been assessed.

The provider completed thorough staff recruitment checks to assess their suitability for the required roles. They were supervised in their roles accordingly and completed an induction and training to keep their practice and skills up to date. However, staff were not suitably deployed in the service at all times.

People had mixed views about the food, their food preferences were recorded, they were provided with enough food and drink and their nutritional plans were followed. However, the mealtime experience was delayed causing some people to become anxious.

Health care practitioners visited people to ensure they maintained good health. Care records held information about people’s nutritional and healthcare needs. Care plans were person centred, but people’s end of life wishes were not always being fully explored.

People told us that staff were not always kind and caring and their privacy and dignity was not always respected. Although we observed acts of kindness, we noted that there were times when a kinder and more caring approach was needed. The provider was meeting people’s cultural and spiritual needs, and people participated in the interests and hobbies that mattered to them.

People were offered independent and impartial advice from an advocate who regularly visited the home. People’s relatives were complimentary about the care their family members received from staff and said they were involved in decisions about their care and any proposed changes in the home.

Staff had completed mental capacity assessments in li

We inspected Carlton Dene Residential Care Home on 26 and 27 September 2016, the inspection was unannounced on the first day and we told the provider we were coming on the second day. This was the first inspection of the service since it had registered with a new provider Sanctuary Care Limited.

Carlton Dene Residential Care Home provides accommodation and respite care for up to 42 older people. The home is set out on two separate floors and divided into four units and provides an emergency bed that is commissioned by the local authority. At the time of our inspection there were 39 people living at the home.

The service had a registered manager. 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.

People spoke positively about the food provided at the home. People's healthcare needs were assessed by the service and plans of care put in place. People were supported to maintain good health by a multi-disciplinary team.

Safeguarding procedures were in place, which were understood by staff. However, risks to people's health, safety and welfare were not continually assessed to ensure people received safe care.

There were sufficient numbers of staff deployed to help ensure safe care. Recruitment procedures were in place and these were followed by the provider.

Some staff did not receive regular supervision to ensure they received adequate support to carry out their roles. Staff had received training and were supported to develop their knowledge further.

‘As required’ medicines and stock checks were not safely managed and the storage of medicines was managed safely. Staff had received regular medicines training.

The cleanliness of the communal areas of the premises were not properly maintained. Checks were undertaken on the premises to ensure it was safe.

Staff cared for people in a caring and attentive way and ensured that their choices were respected. People and their relatives told us staff were kind and knew them well.

People had care plans to tell staff how they wished to be supported and involved in their lives in the home, however some of those plans were not fully completed and reviewed. People were supported with their care in a dignified manner.

People were supported to enjoy a range of activities and pursue their personal interests; however, some people wanted more support in the local community.

Appropriate Deprivation of Liberty Safeguards (DoLS) applications had been made where necessary to the local authority. Staff understood the principles of the Mental Capacity Act 2005 (MCA).

Relatives told us they were not readily consulted about matters affecting the home. There were systems in place for handling and resolving complaints.

Quality assurance systems were in place to effectively improve the quality of care delivered; however, these were not always thorough in identifying and addressing shortfalls that we found. There were systems in place to seek and act on people's feedback. The management team were committed to making improvements to the home. Staff told us they felt supported by the management team.

We found three breaches of regulations relating to safe care and treatment, person centred care and good governance. You can see what action we asked the provider to take at the back of the full version of this report.