CQC report explained · a residential care home, run by Salutem Bid Co
Carrick
11 Carlyon Road, Playing Place, Truro, TR3 6EU
Rated Good: inspectors found the service performing well and meeting their expectations.
What inspectors found, September 2023
Rated Inadequate and placed in special measures; inspectors found serious safety, consent and leadership failures.
This was an unannounced inspection on 24 July 2023. Two inspectors visited the home, met three people, observed care and spoke with staff, relatives and an external professional. They reviewed care records, medicines, incidents, rotas and other records.
The overall rating was Inadequate. Safe and well-led were rated Inadequate. Effective, caring and responsive were rated Requires Improvement. Inspectors found that some staff were not trained to manage distress and restraint safely, care records were out of date, and people were not always supported to make choices or live meaningful lives.
There were some positive findings. Medicines were stored and recorded safely, staff recruitment checks were completed, people were supported to access local activities and health services, and infection control arrangements were generally suitable. However, these strengths did not outweigh the serious failures identified.
The home was placed in special measures. CQC will request an action plan, work with the provider and local authority, and usually re-inspect within six months to check for significant improvement.
Medicines
People were supported with prescribed medicines, which were stored appropriately and recorded accurately. Inspectors did note that records explaining some as-needed medicines were too vague.
“People were safely supported with their medicines as prescribed. Medicines were stored appropriately, and Medicine Administration Records (MAR) had been accurately completed.” from the report
Community access
People were supported to go out, including to a day centre, shops and local walks. The provider was also helping people apply for bus passes.
“People were supported to go out on a daily basis.” from the report
Healthcare support
Records showed that people attended GP and dental appointments when needed. Hospital passports had also been prepared to share important information if someone needed hospital care.
“Records showed people visited the dentist and GP as needed.” from the report
Infection control
Inspectors were assured about most infection prevention arrangements, including the use of protective equipment and responses to infection risks. A visitor toilet tap was not working at the time but was repaired afterwards.
“We were assured that the provider was using PPE effectively and safely.” from the report
Unsafe response to distress
seriousSome staff involved in restraint had not received the required or up-to-date training. On one occasion, a staff member without recent training dealt with an incident alone.
“The failure to ensure staff had the qualifications, competence, skills and experience to enable them to provide care and support safely was a breach of Regulation 12” from the report
Fire and risk checks
seriousRisk assessments contained information that was no longer relevant, and staff did not always have guidance for new risks. Fire alarm tests and other fire safety checks were not completed consistently.
“Weekly fire alarm tests had not been consistently completed. Records showed these had only been done twice in May 2023 and twice in July 2023.” from the report
Consent and restrictions
seriousCapacity assessments had not been reviewed after the provider took over. There was limited evidence that restrictive practices had been properly considered, consented to or justified as being in people's best interests.
“People's care plans included some restrictive practices. There was limited evidence available to demonstrate how people's capacity to consent to each restrictive practice had been fully assessed” from the report
Out-of-date care plans
needs fixingCare plans did not accurately describe people's current needs, goals or skills. This was especially concerning because agency staff were often used and might not know people well.
“Care plans were not an accurate reflection of people's needs. This was particularly important as agency staff were frequently used who would not have a good understanding of people's needs.” from the report
Limited meaningful activity
needs fixingPeople had some outings, but inspectors saw little activity or active support in the home. Quieter people were especially likely to have little access to pastimes.
“Apart from activities associated with eating and drinking we did not see people engage in any activities with staff while in the service.” from the report
Weak management oversight
seriousThere was no registered manager, several management changes and inconsistent recording of learning after incidents. The systems for checking quality, risks and people's experiences were not effective.
“The failure to assess, monitor and mitigate the risks and improve the quality of the delivery of care and support was a breach of regulation 17” from the report
- 01What training has every staff member completed to support people safely during distress or restraint, and how is this kept up to date?
- 02Have all care plans, risk assessments and mental capacity assessments been reviewed since the inspection, and how often are they now checked?
- 03How are restrictive practices being reviewed to show they are necessary, proportionate and agreed in line with the Mental Capacity Act?
- 04What meaningful activities are now available inside the home, especially for people who are quieter or less likely to ask for staff attention?
- 05Who is currently responsible for management, and what evidence can you show that fire checks, incident learning and quality monitoring are now completed reliably?
This was an unannounced first inspection of the newly registered care home, covering all five key questions and infection prevention and control; the service had been taken over by the new provider in November 2022. This explanation was written from the published report of 28 September 2023 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 Carrick
7 rated inspections over 8 years: the service has slipped, from Good to Inadequate.
- September 2023Inadequatecurrent ratingstayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2022Inadequatestayed InadequateSafe: InadequateResponsive: Requires improvementWell-led: Inadequate
- May 2022Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- September 2021Requires improvementdown from GoodSafe: Requires improvementResponsive: GoodWell-led: Requires improvement
- January 2020Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2017Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2022
Registered with the Care Quality Commission on 21 November 2022.
Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.
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