- Care home
Carlton Avenue
We issued warning notices on Achieve Together Limited on 10th September 2024 for failing to ensure safe care and treatment and good governance at Carlton Avenue.
Report from 26 June 2024 assessment
Contents
Ratings
Our view of the service
Date of assessment: 26 June to 19 July 2024. Carlton Avenue is a residential care home which provides support for up to 9 people. At the time of our assessment there were 5 people living in Carlton Avenue, all of whom had a learning disability, as well as a physical disability. We expect health and social care providers to guarantee autistic people and people with a learning disability respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it. We conducted this assessment due to receiving information of concern about supporting people with their medicines and managing the risk of choking. We assessed 21 quality statements, across the key questions of safe, effective, caring, responsive and well led. We identified 5 breaches in relation to safe care and treatment, premises and equipment, person centred care, governance and staffing. People using the service were not adequately protected from the risk of harm. Not all staff had completed essential training and care was not person centred. The provider did not have effective management, oversight and governance systems in place. They had not identified the shortfalls we found during our assessment, nor the issues raised by other healthcare professionals. Learning and necessary improvements had not been made in a timely manner. We have asked the provider for an action plan in response to the concerns found at this assessment. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.
People's experience of this service
People living in the home had their own communication style, which could only be learnt over time. To help us capture the experiences of people using the service, who may not be able to express these for themselves, we spoke with people’s relatives and carried out observations. People told us staff were kind and there were enough to meet their needs. People were supported to access healthcare services. However, they did not always experience a collaborative and joined-up approach to their health, safety and wellbeing. 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. Some relatives also told us they had concerns about the effectiveness of the staff training. People’s relatives said they were not included or involved in decisions about their loved ones’ care and support and important information was not shared with them. People did not benefit from living in a safe environment that was designed to meet their needs. However, they were protected from the risk of infection because the premises and equipment were kept clean and hygienic. People were not assured they would be given their medicines safely and as prescribed. Staff did not consistently follow instructions, nor appropriately seek guidance and approval from professionals when needed. People could not be assured their needs would always be assessed or reassessed in a timely manner. People could also not be confident that staff would follow their individual needs assessments. People using the service could not be assured they would be supported to make a complaint or have their voices listened to. People’s relatives were not confident they would be taken seriously and treated compassionately, if they complained.