King Street - Care Home Physical Disabilities

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

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 good. At this inspection the rating has changed to requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

This service scored 50 (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.

People's needs were not always effectively assessed, monitored, or reviewed. There was a lack of a structured and collaborative approach to identifying and responding to changes in need, which placed people at risk of receiving inappropriate or unsafe care. Important information was often missed or not recorded in care plans. For example, changes in health needs had not always been documented, or important information and changes in need communicated effectively with staff. This meant staff did not have the up-to-date guidance required to support people safely and in line with their assessed needs. This demonstrated a failure to ensure care was consistently effective or person-centred.

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

Positive Behaviour Support (PBS) approaches were not embedded in line with best practise guidance. There was a lack of functional assessments to underpin PBS planning, which limited the development of personalised strategies to support people effectively. Staff did not consistently record incidents using Antecedent-Behaviour-Consequence (ABC) charts, reducing opportunities for reflective learning and hindering a consistent approach to managing distressed behaviours. This inconsistency impacted the service’s ability to identify triggers, patterns, and appropriate interventions, thereby compromising the quality and effectiveness of behavioural support planning.

People who required support with nutrition and hydration and skin integrity needs had national recognised assessment tools within their care records to ensure care was tailored to individual need. Food and fluid charts were in place for staff to record people’s intake and ensure people were supported to eat and drink regularly.

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

Staff, teams, and services did not always work together effectively to ensure people received coordinated and responsive care. There were inconsistencies in how staff recorded the outcomes of health appointments, which led to missed opportunities to review care plans and follow up on changes in people's health needs. For example, staff were not aware of their roles and responsibilities when recording essential information. Some staff recorded information within electronic care records, other staff recorded appointments within paper copy health action plans which had not been reviewed by managers. This lack of robust communication and record keeping meant important information was not always shared or acted upon, impacting the continuity and effectiveness of care.

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.

Care records were updated to reflect people’s dietary requirements, preferences, and likes and dislikes. Improvements had also been made to the information held within the kitchen to ensure staff teams were aware of and could support people’s eating and drinking and dietary needs. However, insufficient staffing and a lack of permanent staff, particularly those able to drive the provider’s transport, had negatively impacted people’s access to healthcare appointments. Staff told us that appointments were often rearranged or missed altogether, which posed a risk to people’s health and wellbeing. One staff member told us, “[Person] has missed two eye appointments due to staff not being available to take them. I have raised concerns about this because it is impacting on their independence”. These barriers limited the provider’s ability to deliver consistent, proactive support for people’s physical health needs.

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

Although some care records included documented outcomes, these were not always reflective of people’s individual needs. For example, we found that care plans for the management of epilepsy and diabetes lacked sufficient detail and did not demonstrate a personalised approach to risk reduction or health optimisation. This meant that people were at risk of receiving care that did not fully support their clinical or personal goals. Additionally, there was limited evidence that outcomes were routinely reviewed or shared with family members, which reduced opportunities for collaborative care planning and transparency. This meant the provider lacked robust systems to monitor outcomes, ensure goals were meaningful and tailored, and embed a culture of learning and accountability that reflected the principles of Right Support, Right Care, Right Culture.

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

People who required support with decision-making had mental capacity assessments and best interest decisions in place; however, these were not always completed thoroughly or reviewed in line with legal requirements. In some cases, documentation lacked clarity or consistency, which meant staff could not be assured that decisions were made in the person’s best interests. This created a risk that care, and treatment may not have been delivered in accordance with the principles of the Mental Capacity Act.