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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 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.

The provider was in breach of legal regulation in relation to person-centred care, consent, safe care and treatment, governance and staffing.

This service scored 33 (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.

The provider did not consistently assess people’s needs before or after admission, and care plans were not kept up to date. Care plans and risk assessments were often undated, making it unclear when they were last completed or reviewed. Pre-admission assessments lacked essential details, meaning risks such as diabetes, and end-of-life care were not fully considered and putting people at potential risk. One person’s care plan lacked detail about their diabetes and how staff were to support the person. This increased the risk of harm related to diabetes complications.

Relatives told us they were not always involved in planning care, and staff confirmed they relied on verbal knowledge rather than written guidance.

One staff member said, “We know people well, but there’s nothing written down about preferences.”

This contributed to the breach of regulation in relation to person centred care, safe care and treatment and governance.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

Care and treatment were not always based on current best practice or clinical guidance. We found no systematic approach to monitoring peoples nutrition and hydration risks, despite one person being at end of life and requiring regular repositioning and thickened fluids. There was no evidence of tools like the Malnutrition Universal Screening Tool (MUST) or Waterlow score being used to assess malnutrition or pressure damage risk. Care plans and risk assessments were undated and contained contradictory information, for example around diet and swallowing needs, placing people at risk.

While some staff demonstrated good practice during observation, such as gaining consent and supporting safe swallowing, this was not consistent across the service. Records showed staff used specific equipment for mouth care, which had not been assessed and was placing a person who was already a known risk of choking at a greater risk. These findings indicated care was not always evidence-based or safely managed.

Staff told us they relied on, “Knowing people well” rather than written risk management guidance or protocols.

This contributed to the breach of regulation in relation to safe care and treatment and governance.

Staff worked together to meet people’s immediate needs, but communication systems were weak.

Handovers were not consistently recorded, with the last written entry dated over a month before the inspection. This meant people’s changing care needs may not be effectively communicated between staff. Care plans lacked clear protocols for managing risks, meaning staff relied on verbal updates.

Staff confirmed information was “Mostly verbal” and not consistently documented.

External professionals were involved, and we saw evidence of GP and hospital appointments being arranged, but outcomes were not always shared with families. One relative told us, “We didn’t know (Person’s name) had been admitted to hospital until after (Person’s name) came home.” This lack of timely information sharing could affect continuity of care.

People were supported to attend health appointments and access services such as dentists and opticians, but opportunities to maintain physical and emotional wellbeing were limited.

Records showed one person was funded by the relevant local authority for 6 hours of community access each week, but this was not provided.

Relatives told us outings were infrequent and dependent on staff availability, with one saying, “(Person’s name) used to go out all the time, now it’s only once a week.”

Staff confirmed low staffing levels restricted activities and social engagement. While some people enjoyed occasional trips and pamper evenings, there was no structured plan to promote healthy lifestyles or prevent isolation. This meant people’s physical and emotional wellbeing may not always be promoted.

This contributed to the breach of regulation in relation to staffing and governance.

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.

The registered manager did not monitor people’s daily records to ensure staff were supporting people with their mobility regularly, identifying signs of abuse and escalating these signs where appropriate. Risks recorded in daily notes were not assessed, monitored, managed and mitigated.

Staff had recorded a person had red, non-blanching skin, this person was meant to be supported with regular repositioning, which was not achieved daily. The provider and registered manager did not monitor assessed needs were being met, which was putting the person at risk of skin breakdown.

The registered manager acknowledged gaps in auditing and said, “I know my auditing has not been completed as I should have done.” This lack of governance and oversight meant improvements were not identified or embedded, and risks remained unidentified and unmanaged.

This contributed to the breach of regulation in relation to safe care and treatment and governance.

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

Consent was sought for day-to-day care, but legal requirements under the Mental Capacity Act 2005 (MCA) were not always met. We observed staff asking for consent before providing personal care and medication. However, there were no mental capacity assessments for people subject to a Deprivation of Liberty Safeguard (DoLS), and no evidence of best interest decisions being recorded.

The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When people lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

The registered manager confirmed, “We don’t do any mental capacity assessments.” This meant the service was not working within the principles of the MCA, which could compromise people’s rights.

One staff member said, “We don’t do mental capacity assessments – I think I’ve seen one from an advocate, but we haven’t completed any.” This meant decisions may not always be lawful or in people’s best interests.

This contributed to the breach of regulation in relation to consent.