Carlton Avenue

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We identified 3 breaches of regulations in relation to safe care and treatment, premises and equipment and staffing. The provider did not always ensure people received safe care. People could not be assured that risks would be managed safely, nor that they would live in a well-maintained, pleasant and welcoming environment. The provider had also not ensured that people’s medicines were managed safely, so people would always receive their medicines as prescribed. There were systems to help safeguard people from the risk of abuse and neglect but authorisations to deprive people of their liberty had not always been reviewed in a timely manner. This meant people were at risk of being unlawfully deprived of their liberty. Incidents and accidents were recorded and staff said they discussed these to learn from them and help prevent recurrences. However, there was limited evidence to show how and when discussions had taken place. Feedback from people’s relatives and healthcare professionals also indicated that lessons were not learned. The provider had safe recruitment processes and ensured there were enough staff on duty to care for people. However, not all staff had completed mandatory training and staff supervisions and competency checks were not consistent, regular or effective.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Some people’s relatives said they did not feel their loved ones always experienced good quality of care, because lessons were not learnt when things went wrong. One relative told us, “We have spoken to [manager]. Initially we felt things might improve; they would listen. Weeks pass by and nothing changes; we start to get despondent.”

Staff told us they had staff meetings and one to one supervision meetings. One staff member said, “We have team meetings and discuss if we are happy and if we have any issues.” Senior managers told us safety events were reported and investigated and that staff knew who to escalate issues to. They told us they had provided an ‘App’ for staff to use on their mobile phones, which had names and telephone numbers of who to report incidents to. However, we found there was limited evidence to show how and when discussions and reflections had taken place. Feedback from people’s relatives and healthcare professionals also indicated that lessons were not learned. Managers told us they were working on a service improvement plan to address the recent safeguarding concerns, which had been raised by the local authority. The managers acknowledged failings at the service and explained how they would make improvements and improve learning.

There were systems in place to ensure incidents and complaints were reported and investigated. We reviewed records relating to incidents, complaints and safeguarding concerns. We saw the lessons learnt columns had been completed but there was no information detailing how lessons had been learned or what action had been taken to mitigate the risk of recurrences. In addition, where action was required, there were no timescales for when these should be completed.

Relatives felt that people did not always benefit from collaborative and joined-up approach to their individual health, safety and wellbeing. One person’s relative told us they took their family member to all their hospital appointments on their own. They said that no staff ever attended the appointments and they never asked how the appointment went afterwards.

Staff told us they shared information about people during handover meetings and prepared an appropriate shift plan for the day ahead. Staff said they would support people with their medical and healthcare appointments if needed and said the local GP also visited the service on a regular basis. However, other evidence we gathered, including feedback from people’s relatives and healthcare professionals, demonstrated that information was not always shared appropriately.

Healthcare professionals raised concerns that the advice they had given around the safe care of people was not being followed. For example, some staff were giving people, who were at risk of choking, food that was not recommended for them and they had been told to avoid.

There were systems and pathways in place for staff to be able to work with healthcare professionals and ensure continuity of care for people. However, we found these were not always effective. This was because staff did not always follow the guidance that healthcare professionals provided, which put people’s health, safety and wellbeing at risk.

Some people’s relatives told us they had concerns about the effectiveness of the staff training. For example, they were concerned that staff did not always support people with appropriate moving and handling procedures or follow their swallowing risk assessments.

Staff told us they had received safeguarding training and were able to explain their responsibilities with regard to raising concerns. One staff member said, “There is a safeguarding team in the council and any abuse would be reported to them, “See It; Report It!” of course I would report this to my manager in the first instance.” Staff we spoke with were able to give examples of potential abuse and explain how and when they would take action. Another member of staff told us they would report any suspicion of abuse or neglect to the manager and if the manager was not on duty, they would report it to more senior managers. However, staff and leaders had not recognised, nor reported, issues within the service that had placed people at risk of avoidable harm.

Our observations showed that people were not always safeguarded in the home. This was because staff and leaders did not always identify and report potential risks and take appropriate action to mitigate them.

The provider had systems and processes in place that were intended to make sure people were protected from abuse and neglect. For example, there was an up-to-date safeguarding policy, a complaints policy and a safeguarding log. However, these processes were not effective, because staff and leaders had failed to identify and report concerns, including when people had been given food and medicines that were deemed unsafe In addition, the systems to ensure care was provided to people in their best interests, were not always effective. Where necessary, people had deprivation of liberty safeguards (DoLS) authorisations in place, but 3 people’s authorisations had not been renewed within the required timeframe. For one person this was a year overdue. If DoLS authorisations have expired, it means that people are at risk of being deprived of their liberty unlawfully. The provider applied to renew the authorisations after our visit to the service.

We spoke with 4 people’s family members as part of this assessment. One family member said they had concerns around their loved one’s moving and handling risks. They told us a recent occupational therapist’s (OT) assessment had concluded [family member] needed support to be hoisted by 2 staff members, but the interim manager had said the mobile hoist was out of action. The family member was subsequently concerned that the person may not always be supported safely with moving and handling, if the OT’s guidance was not followed. Another relative told us that the recent guidelines provided by a recent Speech and Language Therapist (SALT) about how to support a person with eating and drinking, had not been shared with them. This relative explained how they supported the person one day a week in their family home, which meant the person had been put at risk of unsafe care because the relative was not aware of the important guidance that needed to be followed.

Staff told us they were aware of people’s care plans and risk assessment and management plans. However, care staff were not involved in updating these. One staff member told us they did not know if the people using the service were involved in updating their care plans and risk assessments, as it was the shift leader who updated these; staff just read them.

We saw people remained seated in their wheelchairs from approximately 9.30am until 2.30pm. We did not see staff providing any support to people during this time, in order to help relieve people’s pressure areas. We told the regional manager about our observations and they said they would look into it. On other occasions, during our assessment, we observed staff supporting people appropriately with their care needs. We saw one staff member communicating with a person and providing reassurance by telling them what they were doing. Risks to people in relation to the premises have not always been identified or mitigated appropriately. We toured part of the premises and identified several issues which could pose a risk to people. For example, we saw some windows did not have restrictors, which meant they could be fully opened, increasing the risk of a person falling from height. Some of the radiators in people’s en-suite bathrooms did not have protective covers. This meant there was a risk that people could sustain scalding, if they had prolonged contact with the radiators. We looked at some of the hot water outlets and saw these had thermostatic valves to make sure the water was regulated to a safe temperature. However, we could not be assured that the risks to people of sustaining scalding from hot water were being mitigated. This was because the records of hot water temperature checks, which the managers sent to us after our visit, had not been consistently completed to demonstrate the hot water temperature was being checked regularly to monitor that the thermostatic valves were working effectively, so people were protected from the risk of scalding.

The provider’s systems and processes to ensure risks to people were managed and mitigated safely, were not always reliable or effective, because risk assessments and management plans had not been consistently reviewed and updated. One support plan was last reviewed 01 February 2023. Someone had written ‘to be reviewed’ but there were no further updates. Other risk assessments that had not been reviewed in a timely manner included the use of bedrails and people’s bowel health. Where there were risks to people in relation to specific clinical needs, such as where they had a shunt (a passage made surgically to help reduce pressure on the brain) or specific needs in relation to elimination, we could not see that an appropriate care professional had been involved in compiling the risk assessments and management plans. Therefore, we could not be assured the care plans provided accurate information and guidance to safely support people with managing these risks. The process for safely evacuating people living in the home was not effective or reliable. Managers told us fire drills were conducted quarterly and, after our visit, we received a record of the fire drill carried out on 5 June 2024. We saw the target time for evacuation was 3.5 minutes, but the actual time taken was 12.9 minutes. We saw a comment written by someone, which stated, “No one took charge; more communication.” There was no action plan to help improve the response in the event of a fire. From individual records we also saw that not all staff had taken part in a recent fire drill, to ensure they knew what to do. Not everyone’s Personal Emergency Evacuation Plan (PEEP) was up to date. Those we saw were dated October 2022 and had not been reviewed. A Fire Emergency Plan was also not up to date, as it had not been reviewed in February 2023 when it was due. Our findings did not assure us the provider had robust processes to help protect people and staff in the event of a fire.

Relatives felt that people did not always benefit from being cared for and supported in a safe environment that was designed to meet their needs. This was because maintenance issues were not consistently reported or addressed in a timely manner. In addition, the external environment was not appealing and did not meet people's sensory and physical needs.

Staff told us the home had recently been redecorated and said they thought there was enough equipment to care for and support people. The managers we spoke with also confirmed this, but they also acknowledged that maintenance issues had not always been dealt with in a timely manner. Staff told us they were not very familiar with how the new system worked, in respect of reporting repairs that were required or other maintenance issues. As a result, action to address these issues had not always been carried out within appropriate timeframes.

The outside of the home was uninviting and poorly maintained. A skip was in front of the home and the grass in the back garden was long and needed cutting. There were no flowers and some bushes needed trimming back. People using the service could only sit outside under an awning, as they could not safely access the garden itself. This meant the home had not been made as welcoming and pleasant as possible for people using the service. We found the home to be clean overall and there were no odours. People’s bedrooms had recently been redecorated and were personalised. However, in one person’s room we saw that framed pictures had not been rehung or replaced, to make the room more individual and personalised for them.

The provider did not have reliable and robust systems and processes in place to ensure the environment was safe and well maintained. Staff were unsure of the reporting procedure and action they needed to take to complete repairs. As a result, maintenance actions were not always carried out in a timely way. For example, we saw the overgrown areas outside of the home and inside the home saw wardrobes and a vanity cupboard, where handles were missing and had not yet been replaced.

Relatives told us they were not always assured people would receive good quality and safe care because the effectiveness of staff training was unreliable and inconsistent. For example, one person’s relative told us that the effectiveness of the staff was questionable. They explained how their loved one’s shunt had been discussed during a review in October 2023. They said they had asked what the guidance was for a shunt that was blocked but nobody, including the person’s keyworker, knew the answer.

Staff told us they believed their training was appropriate for their roles and they also thought there were enough staff to support people safely. Managers explained that, due to the recent safeguarding concern, they were implementing observational supervisions of all staff, when supporting people at mealtimes. This was to ensure staff understood and followed the SALT guidance in people’s support plans. Furthermore, managers said they were reviewing staff training to ensure there was 100% compliance in Dysphagia (swallowing difficulties) amongst other training. However, we identified that only 1 of 6 staff attended the mandatory dysphagia training arranged after our visit and the managers could not provide us with any reason for this, nor any follow up action. This meant that people using the service remained at risk of being supported by people who did not understand or follow the guidance on how to manage their dysphagia.

We saw there were enough staff on shift during our visit to support people safely and respond to their needs in a timely manner. We also observed positive interactions between staff and the people who lived there. The environment was relaxed and people looked comfortable with staff who appeared to know them well. People looked clean and well cared for.

The service followed safe recruitment practices and new staff completed inductions. However, we reviewed the staff supervision and appraisal spreadsheet and saw that 2 staff had not had a supervision meeting for 7 months. In addition, the format of staff supervisions and team meetings lacked structure, quality and effectiveness. For example, there were no records of reflections on practice nor discussions about people’s wellbeing or their individual health conditions, such as dysphagia and epilepsy. There were 4 people using the service who had been diagnosed with dysphagia and had associated support plans based on SALT guidance. However, there were no systems or processes in place to assess staff’s understanding and competency in respect of supporting people in accordance with the SALT guidance. We reviewed the staff training log and saw that not all staff had completed essential training. For example, 8 out of 16 staff did not have up to date training in epilepsy awareness and administration of an epilepsy medicine when someone has had a seizure and 5 out of 16 staff did not have up to date training in dysphagia. Following the inspection visit, social and healthcare professionals consistently shared their concerns in meetings about the effectiveness of the service’s inhouse staff training and the potential impact on the quality-of-care people received.

People using the service were protected as much as possible from the risk of infection because the premises and equipment were kept clean and hygienic.

Staff told us they had enough protective equipment to help keep people safe from the risk of infection. Staff said they frequently cleaned the home, including people’s bedrooms and bathrooms.

The areas of the home we observed were clean, hygienic and free from unpleasant odours. Clinical waste was disposed of in appropriate bins, although one of the pedal operated bins was not working and needed replacing. We gave feedback to managers about this and they assured us they would address the issue without delay.

The provider had an infection prevention and control (IPC) policy and IPC audits were carried out regularly. Staff had completed training in infection control and we saw they completed a cleaning schedule, which confirmed when and what cleaning tasks had been undertaken. Our observations assured us that the cleaning regime was adequate. There was no food hygiene certificate in the home and the provider told us they needed to request a copy. The Food Standards Agency website showed the service had achieved a 4-star rating in February 2023.

People could not be assured that they would be given their medicines safely and as prescribed. This was because staff did not consistently follow instructions, nor appropriately seek guidance and approval from professionals such as a pharmacist and GP when needed.

Staff on duty told us they had completed medicines training and their competency was assessed, to make sure they could support people with their medicines safely. However, evidence we saw during our visit did not corroborate with what staff told us. For example, medicines were not always signed for correctly and medicines were not always given as prescribed.

Systems and processes to ensure people always received their medicines safely were ineffective. A new 28-day medicines cycle started two days before our visit, but medicines had not always been signed for. In one case, it was evident medicine had not been administered as prescribed. The previous cycle of medicines showed a person had not received a medicine for 7 days, because it had been out of stock. Staff did not always record the quantity administered, where it was prescribed to ‘give one or two’. This meant the effectiveness of the medicine could not be reliably monitored. We identified instances where medicines were prescribed to be given regularly but staff administered them ‘as required’ (PRN). This meant staff were not giving people their medicines as prescribed and they had not requested a medicines’ review to have the instructions changed if needed. Some medicines had a limited lifespan once opened. We saw liquid medicines where the date opened had not been recorded. This meant people were at risk of being given out of date medicines that may no longer be effective. Staff dissolved one person’s tablet before administering it through a gastrostomy tube. However, records were not available to show that approval from a pharmacist had been sought, to confirm it was safe to administer the medicine in this way. One person was given their medicines covertly, disguised in food or drinks. However, the covert medicines assessment was unavailable on the day of our visit. It was sent to us 3 weeks later, but there was no date or signature on the most recent review, which appeared to have been in July 2022. This meant we could not be assured the assessment was still relevant and appropriate for meeting the person’s medicines needs. Medicines were stored in a locked cupboard in each person’s bedroom. Storage temperatures were regularly monitored and staff took appropriate measures if it was too hot. Equipment, such as nebulisers, were clean and in good working order.