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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last inspection we rated this key question as requires improvement. At this inspection the rating has changed to Good.

This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

The provider completed a care needs assessment when this was required. When there was a change in need, they would update the care plan. However, we found one person’s care plan had not been updated following a change in need.

We saw health professionals were involved in the assessment of people’s health care. For example, a Speech and Language Therapist (SALT) had assessed a person’s eating and drinking needs and Occupational Therapy (OT) referrals had been made for people. People had a pen picture which set out the most important information staff needed to know about them to be able to support them in the right way. Communication passports had been developed which guided staff about how people with no verbal communication may present when they were happy, sad or in pain.

The provider planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. We saw people had DisDAT (distress and discomfort assessment tool) used to help staff identify signs of distress in people with limited communication abilities.There were SALT eating and drinking guidelines for one person, and we observed staff support the person in line with the guidance.Leaders told us positive behaviour support guidance had been put in place for people with input from the organisation’s behaviour support team and mental health nurses.Care was being tailored to meet the needs of people who live in the service. However, records for one person had not always been updated to reflect their current needs. This was addressed by the provider during the inspection.

The provider worked well across teams and services to support people.Records demonstrated the service worked well with partner agencies including GP’s, SALT and Occupational therapists to ensure people received appropriate care and treatment.One external partner described the provider as proactive in making referrals and implementing recommended changes for people with dysphagia.We saw a handover system was being used by staff. Staff told us they read the handover notes to ensure they were aware of what was happening in the service and if there was anything they needed to do.

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support. One relative said, “they monitor [person’s] weight regularly, because [person] had gained weight.” One staff member explained how they had supported a person to the GP because they were concerned about their weight loss. The staff member confirmed the person was now a healthy weight following a period of monitoring and supplements prescribed by the GP.

The provider monitored people’s care and treatment to continuously improve people’s quality of care and identify people’s changing needs. Staff said they monitor people for any health concerns. One staff member said, “Any signs and symptoms are reported and recorded immediately, and the GP is contacted for advice …” An external health professional said staff completed required eating and drinking monitoring logs as requested to support their assessments.However, records did not always demonstrate how people’s needs were monitored. For example, a record for updating changes in a person’s needs had not been completed. However, we saw appropriate health professional referrals had been made.

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment.Records demonstrated assessments of people’s capacity were completed for decisions. Staff and leaders told us best interest meetings were held and included the person and family or an advocate. Staff had a good understanding of the Mental Capacity Act (MCA), and records showed they had MCA training.One staff member explained how they sought consent with people prior to supporting them with personal care. The staff member said. “If you took someone to the bath, you put their hand in the water, and they consent to have a bath... if not there would be an obvious gesture of not consenting.”