Carlton Avenue

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We found a breach of regulation in relation to good governance. There was unstable and inconsistent management in the service, which meant staff did not know or understand how to ensure any shared vision and strategy could be achieved. Leaders did not consistently demonstrate or promote a positive, compassionate, listening culture that was focused on learning and improvement. We were not assured that equality and diversity was consistently promoted. Leaders at every level were not always visible and did not consistently lead by example. Leaders were not always alert to poor cultures or practice, which meant they did not take timely action to address any issues. Leaders did not actively promote staff empowerment to drive improvement. When concerns were raised, leaders did not always investigate these thoroughly and ensure lessons were shared and acted on. The service did not have clear and effective governance, management and accountability arrangements. Data and notifications were not consistently submitted to external organisations in a timely manner. Staff and leaders did not consistently ensure that people using the service, their families and carers were involved in developing and evaluating improvement and innovation within the service. The managers talked through plans they had recently put in place, which included holding staff meetings to support staff with their wellbeing. The provider told us they understood that mistakes had been made. They said they were reflecting on what had gone wrong and were supporting the staff though this.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they had not always had a consistent manager to support them and help create the open and supportive culture that was required when caring for people with multiple needs. One staff member told us they did not feel the service was being supported by the wider organisation. The managers talked through the plan they had put in place following the recent safeguarding concerns meeting. This included holding staff meetings to support staff with their wellbeing during the process. The provider told us they understood that mistakes had been made. They said they were reflecting on what had gone wrong and were supporting the staff though this.

The last permanent manager left the service in December 2023, prior to being registered. Since then, the service had been managed by peripatetic managers. The lack of consistent management support had led to the vision and priorities of the service not taking a prominent position. The provider had implemented an internal action plan from which they were working on and discussing their progress on a weekly basis with the local authority.

The peripatetic manager was on leave at the time of our visit. Staff told us that the peripatetic manager was visible, and they were supportive. One staff member said, “We work well as a team and are flexible and support each other and that includes the manager.” They also said that there had not been much support previously from more senior managers, which meant it was difficult for the manager overseeing the service to maintain high quality care for people using the service. The managers we spoke with during our visit said they understood the importance of delivering safe care and treatment. They told us they were knowledgeable about issues that affected the quality of people’s care and said they addressed these quickly. However, evidence gathered throughout our assessment and site visit, demonstrated that many issues had not been identified or addressed prior to the involvement of the local authority and the commencement of our assessment. In addition, when we visited the service, the manager on duty said it was their first day. This person did not know the names of the people using the service and had no knowledge or understanding of their needs, nor the needs of the service as a whole. Neither this manager, nor the senior managers could access a lot of the important data and documents we requested during our visit.

Processes to help ensure the service was able to provide compassionate and high-quality care to people were ineffective. For example, there was inconsistent leadership and oversight, audits were not fit for purpose and records were not available to demonstrate how various aspects of the service were being managed safely. The line managers who visited the service on the day of the visit were new to the service and did not have a good knowledge of the way the service operated and about the care of the people using the service. There was little continuity in managing the service.

Staff we spoke with said they felt they could speak to the peripatetic manager and regional managers if they had any issues and demonstrated a good understanding about how to raise any concerns they had. One staff member told us, “To raise any concerns, apart from speaking to managers, we can use the complaints and whistleblowing procedures. We can easily access these though the Achieve Together app on our phones. We can access all the procedures and numbers and we can call everyone.”

The provider had an up-to-date whistleblowing and complaints procedure in place. We saw that 12 out of 19 staff (63%) had completed a quality assurance survey in November 2023. The provider’s summary report had been incorrectly calculated, as the overall results showed a total response of 101%. 43% strongly agreed with positive statements about their work and 55% agreed. However, 8% had responded with ‘disagree’ to the specific question, “I feel able to speak freely, offer feedback and raise concerns’. There was no response given to staff regarding this and no follow up or action plan.

Staff and managers told us they completed regular audits and quality checks of the service. However, they also acknowledged these checks and audits had not been effective in some areas.

The provider did not have effective management, oversight and governance systems in place. They had not identified the shortfalls that we found during our assessment nor issues raised by other healthcare professionals. Subsequently the necessary improvements had not been made in a timely manner and people using the service were not adequately protected from the risk of receiving unsafe care. There was a lack of oversight at the service and quality assurance processes were ineffective. The audits of care records had not identified that care plans and risk assessments had not been regularly reviewed and were out of date. The quality checks and audits of the premises had not picked up on the issues and concerns we identified in and around the environment. Medicines audits had not identified that medicines were not being managed appropriately and people were not always receiving their medicines safely and as prescribed. The provider’s checks and audits had not identified that the DoLS authorisations for 4 out of 5 people who used the service were out of date.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The managers told us that, from now, their focus would be on continuous learning and improvement for the service. They said this would include consistent management arrangements, to ensure the safety of the people they supported with choking risks, dysphagia and medicines management. The managers acknowledged that this had not always been the case. Managers told us they had implemented observational supervisions for all staff around supporting people at mealtimes, to ensure there was a comprehensive level of understanding in respect of people’s SALT and Support plans. Managers told us they were reviewing staff training and would ensure 100% compliance in respect of dysphagia, PEG & medicines. The managers were providing updates to the local authority’s safeguarding leads and CQC every week. However, the managers were still unable to account for staff who had failed to attend the dysphagia training provided by local healthcare professionals, that was arranged a few days after the inspection.

Evidence collected during the assessment showed that there had not always been continuous improvement at the service and sustainability of safe and effective practice to ensure people consistently experienced good quality care. Managers and leaders had failed to prevent the quality of the service from deteriorating. They had also failed to address issues in a timely manner and ensure learning from mistakes was applied and monitored to ensure improvements were sustained. This meant people were at risk of poor outcomes in respect of their quality of life. The implementation of good care practices was not always adhered to and staff were not always involved in reflection and collective problem-solving to maintain good quality care.