Carlton Avenue

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We found a breach of regulation in relation to person centred care. People did not consistently have care and support that was well coordinated and person centred. People’s relatives, and others who knew and cared about those using the service, did not always have opportunities to be involved in planning their care and support. People’s individual preferences and characteristics were not always being supported or given consideration in respect of sexuality and individual health screening procedures. Not everyone was aware of the complaints procedure and some people did not feel their complaints were listened to or acted upon. People using the service looked happy and comfortable in the presence of staff who knew them well.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Relatives could not be assured that they would always be involved in planning their loved ones’ care and support. They told us they had concerns around the support and care their loved ones received. They said they were unhappy with the management of the home and felt this had an impact on the way staff supported their loved ones. They felt communication was inadequate and cited concerns around staff’s lack of knowledge when they were asked questions about their family member.

Staff told us they knew people well. They said they knew what people liked to do and how they liked to be supported. However, managers and leaders did not demonstrate the knowledge or oversight, to ensure people received person centred care. For example, the manager supporting the service on the day of our visit told us they did not know the people or their needs at all. They did not know people’s names and could not access many of the records that were important and relevant to people’s daily lives.

Some staff had worked in the home for a long time and appeared to know people well. People using the service looked happy and comfortable in the presence of these staff members. People’s activity plans for the week were normally displayed in the main entrance of the home. However, when we visited the service mid-week, we saw these were empty. Nobody was supported to go out during our visit, although we observed staff doing karaoke with people in the garden. From our observations, we were not assured that people care and support was genuinely centred around each individual person.

We did not look at Care provision, Integration and continuity during this assessment. The score for this quality statement is based on the previous rating for Responsive.

We did not look at Providing Information during this assessment. The score for this quality statement is based on the previous rating for Responsive.

People's relatives were not confident that if they complained, they would be taken seriously and treated compassionately. Two of the 4 relatives we spoke with were not aware of the providers complaints procedure. One person said, “We know we have the manager but don’t know about company [complaint] process.” Another relative told us, “They are terrible for quite a while; we spoke to them, saw some changes, then it goes back to normal”. A third relative said, “If we don’t phone to see how [Family member] is, they never phone us”.

The managers we spoke to during our visit told us they were committed to ensuring people’ relatives were listened to. Staff also told us they would report to the managers, if any relatives complained to them about the care of their family members.

The service had a complaint process, which was also available in an easy read format. We saw complaints received in the past had been recorded and investigated. The outcomes had also been recorded and when things had gone wrong, apologies were provided to complainants. The last complaint was recorded as having been in June 2023. According to the records no other complaints had since been made. However, some relatives told us they had raised concerns with the service recently. We could not find any evidence to demonstrate how they were responded to, or how their feedback was acted upon. We could not see any evidence that learning from complaints and concerns was seen as an opportunity for improvement and staff could not give examples of how they incorporated learning into daily practice. We saw staff quality assurance surveys had been completed, but surveys had not been provided to or completed by people using the service, their family members or external professionals.

We did not look at Equity in access during this assessment. The score for this quality statement is based on the previous rating for Responsive.

People could not be confident that leaders and staff were alert to discrimination and inequality and would make reasonable adjustments to support equity in experience. Relatives felt that people’s individual preferences and characteristics were not always given consideration and promoted in respect of sexuality and individual health screening procedures.

Staff and leaders were not able to demonstrate how they ensured people did not experience discrimination. Neither staff nor managers had identified that people had not been provided with opportunities to make decisions regarding certain health screening procedures. In addition, no consideration had been given to support people in respect of expressing their sexuality. This meant we could not be assured that staff and managers would make reasonable adjustments to support equity in experience and outcomes for people.

We noted that some sections in female service users’ care plans, such as breast screening and cervical screening, were marked as ‘not applicable’. However, there was no rationale explaining how this decision had been reached or any evidence that relevant healthcare professionals had been involved in this particular decision-making process. Sections in people’s care plans that covered sexuality were blank. This did not assure us that people’s individual preferences and characteristics were being supported or given consideration and should have been explored further.

We did not look at Planning for the future during this assessment. The score for this quality statement is based on the previous rating for Responsive.