Archived: Clubworthy House

On this page

• 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 assessment we rated this key question good. At this assessment the rating has changed to inadequate.

This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

This service scored 38 (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 did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

Care plans lacked sufficient detail to guide staff in delivering person-centred care. For example, one person’s care plan did not provide any information about how their health condition affected their daily life or support needs or how to mitigate risks associated with the condition.

Although the provider had long-standing relationships with the people they supported, this familiarity was not reflected in the quality of documentation. Care plans included some personal preferences, such as favourite TV shows or preferred seating arrangements at the theatre, but did not explore people’s aspirations, goals, or how they wished to develop independence.

Assessments were not always consistent with the level of choice and control people were reported to have. This meant people were at risk of receiving care that did not fully meet their needs or reflect their preferences.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

The model of care at Clubworthy House was not aligned with the principles of Right support, right care, right culture. People were not supported to make meaningful choices about their daily lives, and routines were rigidly structured around the preferences of the provider.

Care plans did not reflect best practice in supporting people with learning disabilities or autistic people. For example, one person’s care plan stated they liked to be reassured when anxious but gave no guidance on how staff should do this. Incident records showed repeated episodes of distress, including shouting, throwing objects, and self-injury, yet there was no evidence of positive behaviour support planning, trauma-informed practice or de-escalation strategies.

There was no evidence the provider used recognised tools or frameworks to assess or plan care. Risk assessments were narrative-based and lacked measurable outcomes or review dates. Staff received training, but there was little evidence learning was embedded into practice. One staff member said, “You get trained, but you can’t use it. Everything has to be done their way”.

The provider did not always work well across teams and services to support people. They did not always work openly with other health professionals.

For example, one person had told health professionals they wanted to consider an alternative placement. There was no evidence the provider had explored this possibility with the person or supported them to make an informed choice.

Where health professionals had tried to engage with and support the service in relation to concerns that had been raised, they had encountered resistance and found the provider unwilling to work openly or acknowledge concerns. The provider obstructed information sharing and dismissed the service user’s opinions, challenging the health professional and making complaints about their conduct, rather than working in collaboration to support the person’s needs.

Two health professionals told us they felt unable to visit the property alone due to the provider’s conduct.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

People were well supported with their day-to-day health needs by staff, however, there was a lack of planning for the future and people did not have health action plans to support them to manage their healthcare needs.

People were supported to attend health appointments and access specialist services. Records showed involvement from dentists, podiatrists, and other health professionals. Staff described how they used strategies such as playing music during appointments to help people feel calm and comfortable.

We received positive feedback from some health professionals. One said, “I feel Clubworthy House excels in their communication and responsiveness to me as a professional. The service providers ensure I am aware of any [specialist area] related concerns that they may have at the start of any appointment, they actively seek to question and understand any issues and want to know what they need to do to resolve these. They take onboard any treatment advice and act on it immediately”.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

There was no evidence of a structured approach to monitoring outcomes or evaluating the impact of care. Incident records were inconsistent and lacked analysis. Several reports described episodes of distress or conflict, but there was no evidence of follow-up, learning, or changes to practice.

The provider did not use recognised tools or frameworks to measure progress or outcomes. There were no goals or targets in care plans, and no evidence of people being supported to achieve personal aspirations. There was no evidence people were able to explore new interests or hobbies that did not align with those of the provider.

The lack of outcome monitoring meant people were at risk of receiving care that did not meet their needs or support them to develop skills, independence, or confidence.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

At the time of inspection, there were no mental capacity assessments, despite one person being subject to a Deprivation of Liberty Safeguards (DoLS) authorisation with conditions requiring capacity assessments to be completed. The provider completed 12 assessments following the inspection, but there was no evidence people were supported to understand or participate in decisions about their care.

The provider’s approach to consent was inconsistent and they planned how people spent their time in advance. This placed people at risk of receiving care that did not respect their autonomy or legal rights.