This inspection took place on 14 August 2018 and was unannounced.

The last inspection was carried out in March 2017. The overall rating for the service was ‘Requires Improvement. We found the provider was in breach of Regulations 12 (safe care and treatment), 15 (premises and equipment) and 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During our comprehensive inspection in August 2018 the home demonstrated to us that improvements had been made.

Carlton House is a care home registered to provide care to up to 24 older people. There were 22 people living at the home, the majority of whom were living with dementia.

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.

At this inspection, we found that significant improvements had been made in relevant areas as detailed throughout this report. The registered manager had a clear sense of responsibility and had led a management team to establish robust processes to monitor the quality of the service. A range of quality assurance processes, including surveys, audits, management of accidents and incidents, better management of complaints had been used continuously to drive improvement.

There were effective systems and processes in place to minimise risks to people. We saw evidence that risks to people had been identified, assessed and reviewed. Safeguarding policies were in place and staff were aware of how to raise concerns. Staff had been recruited safely. They underwent appropriate recruitment checks before they commenced working at the service to ensure they were suitable to provide people's care. We found evidence the service regularly checked and recorded the temperatures of the water outlets. We also found robust arrangements around the management of accidents and incidents, medicines and risks associated with poor infection control.

Although there were sufficient staff, we recommended the service reviews the deployment of staff during busy times.

People gave consistently positive feedback about how the service was meeting their needs. The service worked together with other health and social care professionals to deliver effective care and treatment. People were supported by staff who had the skills and knowledge to carry out their role. The staff received regular training and support. We also saw that people's capacity to make choices had been considered in line with the Mental Capacity Act 2005 (MCA). We found the environment was now more supportive and enabling for people with dementia.

People told us staff were caring and compassionate. We observed that staff treated people with respect and dignity. People's individual preferences were respected. Staff had a good understanding of protecting and respecting people's human rights. They treated people's beliefs and cultures with respect.

People received person centred care. We found the content of the care plans to be detailed and person centred. We saw evidence that they had been consulted when their care plans were written. We also saw that care plans were now being regularly reviewed and updated to ensure they reflected people's changing needs and wishes. The previous inspection had found failings in this area. People and their relatives confirmed that they could complain if needed. There was a complaints procedure which they were aware of.

There was a programme of activities organised by the home, but not all people participated in the activities that were on offer. The amount of activities on offer may not have been sufficient for people with dementia. We recommend that the service seek advice and guidance from a reputable source regarding act

We carried out an unannounced inspection of Carlton House on 10 March 2017. The service is registered to provide care and accommodation for 24 adults. At the time of our inspection there were 23 people living in the home.

At our last inspection in January 2016 we found the service had made improvements. We rated the service as ‘Requires improvement’ because it was too early for the registered provider to demonstrate the service was safe and well-led during that inspection. To do so, the provider needed to demonstrate a consistent track record of improvements. This inspection was to check improvements had been sustained and to review the ratings.

The home has a registered manager 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.

At this inspection, although we identified improvements had been sustained since our last inspection, there were concerns in different areas.

People told us they felt safe living in the home and that staff were kind and caring. However, we found issues with poor maintenance of the building. Some rooms on the first floor did not have window restrictors fitted to prevent people from climbing through them and falling from height. There were also problems with the provision of hot water to some rooms.

Some care plans were person centred and provided guidance to support those people, but other care plans did not contain sufficient information to enable staff to fully meet people's needs.

The service had not made sufficient adaptations to assist people living with dementia with orientation and safety. There was a lack of suitable pictorial signage around the service to help aid the orientation and reduce confusion for people with dementia.

Quality monitoring systems were not effective. The audits that had been carried out had not identified any of the deficiencies we found during this inspection.

There were policies and procedures in place to guide staff in relation to safeguarding adults. Staff were able to tell us who they would contact internally and externally if they were concerned about a person living in the home.

We found safe recruitment processes were in place and staff received an induction when they started working at the home. Many of the staff had qualifications in health and social care. They had also completed mandatory training. There were systems in place to ensure staff received supervision and appraisal.

People had access to sufficient quantities of nutritious food and drink throughout the day. People told us that meals were good and the menu showed there were alternative options if someone did not want what was on the menu.

People's rights were protected because staff understood and followed the Mental Capacity Act 2005.

We found three breaches of regulations. You can see what action we asked the provider to take at the back of the full version of this report.

This unannounced comprehensive inspection took place on 12 and 14 January 2016. The last inspection took place on 22 January 2014. The service was meeting the legal requirements at that time.

The service is a care home which offers care and support for up to 24 older people. At the time of the inspection there were 22 people living at the service. Some of these people were living with dementia. The service comprises of a detached building with three floors.

The service had a registered manager 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.

Our key findings across all the areas we inspected were as follows:

Specifically, we found the service to be requiring improvement for providing safe and well-led services. Therefore, the overall rating is ‘requires improvement’.

In addition to a medicines issue, we identified the concerns which led to a rating of requiring improvement in safe and well-led apply to the fact that although improvements had been carried out following a significant event; it was too early for the registered provider to demonstrate the service was safe and well-led. To do so, the provider must demonstrate a consistent track record of improvements. We will keep the service under review to check if the noted improvements are sustained.

We observed that prior to a significant event; people receiving care were exposed to risk of harm because some aspects of the premises were not always maintained to help keep people safe. We also noted that the quality assurance processes of the service had not identified these shortfalls. For example, the patio door alarms had been disabled for a long time despite this posing a risk to people living at the home, who were predominantly at risk of leaving the building unsupervised for their safety.

However, we also found that the service had an effective system in place for reporting and recording significant events. Following the significant event, lessons were shared to make sure action was taken to improve safety.

We found the service had made improvements to make people safe. People told us they felt safe and secure at the home. However, arrangements for medicines management were not always safe. In one instance we observed medicines for one person were not being administered according to instructions. This meant potentially this person was receiving inadequate pain relief to meet their needs.

Staff were trained in safeguarding adults and understood how to recognise and report any abuse. Care staff understood what constituted abuse and were aware of the steps to take to protect people.

People were supported by staff who were well trained. Staff received specific training tailored to people’s individual needs in addition to mandatory training.

People were supported to eat and drink sufficiently to maintain a balanced diet. People were regularly consulted about their food and drink choices and were supported to express their preferences for meals and snacks.

The registered manager and staff understood their responsibilities in relation to the Mental Capacity Act 2005. People were involved in making decisions about their care and support and their consent was sought and documented.

People told us they were treated with dignity and respect. Care staff understood the need to protect people's privacy and dignity. Staff anticipated people’s care needs and attended to people in a timely manner.

People felt able to complain or raise concerns, the home supported them to do this and concerns were resolved quickly.

Systems to monitor the quality of the service had been improved.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You c

People told us that they understood the care choices available to them, and that they could have their views taken into account in the way their care was delivered. A person told us, "They are very good, they explain things to you.” Another person told us, “They do listen to me.” Another person said, “We have alternatives. I go down for lunch and eat tea in my room if I wish to do so.”

People's needs were assessed and care was planned and delivered to meet people's needs. A person told us, “I can always talk to staff or the manager, they are very helpful." People’s care was regularly reviewed and their personal information was held securely. A person told us, "I’ve seen the care plan.”

We viewed a selection of staff records, and saw that relevant checks had been carried out when the home employed staff. Staff had opportunities to gain appropriate qualifications. A person told us, “They don’t seem to go through a lot of staff; the staff seem stable.”

The home kept records of general maintenance of the building, people who used the service and staff. Records were archived and destroyed in accordance with retention schedules.

We spoke with three people who use the service and three members of staff including the manager. All the people we spoke with told us they were happy with the staff and the care they received. Comments included, "We make suggestions to staff which they are normally fine with" and "We get to do what we want". We observed staff obtaining people's consent before providing care. The provider ensured either consent was obtained from the person who uses the service or by someone authorised to make decisions on their behalf.

We spoke with six people who use the service, one relative, and four members of staff including the manager. There were some instances where the provider had not obtained the consent of people who use the service or ensured that decisions taken on their behalf were in their best interests. Some people we spoke with said that the staff did not support them to do some of the things they wanted.

People were cared for in a way that maintained their welfare and safety. People we spoke with told us they were happy with their care and treatment but said that they wished they go out into the community. We observed some staff caring for people in an unprofessional manner.

The provider stored, managed and administered medication safely. People we spoke with said they were able to receive medication when they required. We observed medication being administered safely.

All the people we spoke with said they were happy with the staff. The provider made sure that through recruitment checks were made on all staff before they were employed.

Some people told us that they had been involved in planning their care. We found most of the provider's records had the necessary information regarding people's needs but some records were not complete.

People said the staff treated them with respect and maintained their privacy and dignity. They told us that surveys had recently been carried out and they also had meetings at which they could express their views, which were listened to. An example given was a request for changes to the menu, which had happened.

People spoke positively about the staff and said they were very good and looked after them well. They said call bells were answered promptly when they called for assistance. People we asked knew what medications they were taking and why, and were able to ask staff if they had any queries about their medication. They also said they could see the GP when they needed to. We asked about the food and were told there was (good) variety and choice and it was tasty. Visitors we spoke with were happy with the care their relatives were receiving. People said there were activities arranged in the afternoons, which they enjoyed.

People said they were able to raise any concerns they had with the manager and staff. Visitors told us they were kept informed of any concerns about their relative.