Waters Park 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 Outstanding. This meant people’s outcomes were consistently better than expected compared to similar services. People’s feedback described it as exceptional and distinctive.

This service scored 87 (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 service’s Multi-Disciplinary Team clinicians always carried out a detailed in person assessment of each person’s needs before they were accepted to be admitted to the service. They travelled across the country to carry out these assessments. For example, professional staff had travelled to Aberdeen from Plymouth to carry out an assessment. The service ensured it could effectively meet a person’s needs before they were admitted to their service by finding out about the whole person.

The service continued to use paper based systems for documenting how people’s needs were met. However, care plans and risk assessments were written and stored digitally, with printed copies produced from the limited IT system. Once the newly purchased IT system is implemented , all assessments, care plans and risk assessments will follow new formats. The care planning completed by the service gave a complete picture of the whole person.

Each clinical specialism, including Physiotherapy, Occupational Therapy, and Speech and Language Therapy (SALT), had their own planned process for rehabilitation. We reviewed one person’s progress through SALT rehabilitation. This had followed the IDDSI (International Dysphagia Diet Standardisation Initiative) levels, however it was stressed by the SALT qualified member of the MDT, that progress was led by the person themselves at their own pace.

The provider always 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. They delivered exceptional rehabilitation evidence-based good practice and standards.

The service provided highly effective support to people with very complex physical and psychologically distressed needs, to then be supported and rehabilitated effectively. Many people improved rapidly from the day of admission, reflecting the exceptional effectiveness of the Multi-Disciplinary Team (MDT) approach. This involved the whole staff team of the service’s managers, nurses, Physiotherapists, Occupational Therapists (OT), Speech and Language Therapist (SALT), care support staff and ancillary staff. The service had also recruited a psychologist who was soon to begin work at the service.

Within a relatively short period of time following admission, people were making remarkable progress as a result of the highly effective support provided to help them regain abilities. This included improvements in mobility, dexterity, eating and drinking orally, and psychological stability, allowing them to return to the community. People had moved into the service only months earlier for rehabilitation and were already being assisted to move on into supported accommodation back into their community. One professional said about the service, “The therapy support is amazing”.

The provider always worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once.

The MDT and support staff worked exceptionally well together as one highly effective team to deliver real rehabilitation for people with highly complex and distressed needs. One of the nurses said, “I do enjoy (my work). I feel very supported by the management. I enjoy supporting the clients and having an overview of their needs and (I am) very glad I am working alongside the MDT team with therapy and everything else, and I enjoy having the MDT meetings where we discuss our clients’ needs. I feel we are delivering high standards of care.”

The service worked very closely with the acute health and social care services in Plymouth and Devon. There was a great deal of constructive communication between the home’s MDT staff and the professionals working in the community. This ensured people received the best possible support while using the service and were then able to move on successfully.

The service did all that they could on behalf of 1 person to support them to move back into the community. The service very actively and effectively supported the process of people moving on from the service. Staff from people’s new community support teams were very well supported. They were encouraged to come into the service to work with their new clients, and the MDT in the home went out to support their new community support teams before and after discharge from the service.

The provider always supported people to manage their health and wellbeing to fully maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

Some people entered the service with PEG (percutaneous endoscopic gastrostomy) nutrition systems in place. The service was exceptionally effective in supporting people to regain safe oral nutrition and hydration, through carefully managed and individually designed rehabilitation processes, led by the service’s speech and language therapist. The MDT worked with the whole person as a highly effective team through these processes. This ensured all of the person’s physical and psychological needs were successfully met, while also achieving the person’s objective of regaining oral eating and drinking.Where people were unable to move on from a PEG nutrition system the service’ staff were very experienced, trained and competent, to manage this method of nutrition and hydration safely and effectively over extended periods.

There was a main service kitchen for the preparation of people’s routine meals. There was also a supervised kitchenette which gave a facility for people to use to safely regain cooking and drink preparation skills. People were actively using this facility as part of their rehabilitation. People were offered choice of food options apart from the main meal menu plan option. For example, a relative said, “If (my relative) does not like what is on, they offer (them) an omelette or a toastie and (the person) is more than happy with what they offer (them). They will always try (offer) something else.”

The provider monitored all people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves.

The service was exceptional in their continuous monitoring of outcomes for each person they supported. Weekly MDT meetings reviewed the effectiveness of each person’s support. These always sought to improve the person’s quality of life by continuously seeking new opportunities for rehabilitation improvement, and to support new stimulating activities to always maximise the person’s quality of life.

Everyone experienced completely individualised, varied and active lifestyles which included social, entertainment, fitness and skill development activities designed to specifically meet each person’s individual needs, preferences and choices.

The service supported several people with complex health conditions. The care home had the necessary equipment to take full observations of people’s health. For example, the service was using a blood oxygen saturation monitoring machine. Where people had declining health conditions, the MDT continuously reviewed their condition and adapted support so the person always maintained the maximum abilities possible for as long as possible.

We spoke with a person who was being supported with intensive rehabilitation by the service. They were experiencing multiple activities outside the home, sometimes more than once each day, and multiple therapy interventions each day. Their progress had been rapid since entering the service. They were highly positive and enthusiastic about their life, now that they were supported by the service.

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment.

Many of the people that lived in the care home had cognitive impairments and some might lack capacity to consent in some areas. Where people lacked capacity, this was fully considered in the delivery of their care.

For example, some people’s personal money and cigarettes were held safely for them by the service. We saw people freely asking for these as they wanted to access them. These arrangements were appropriately in place to ensure people and their personal effects were kept safe. Where people lacked capacity to consent to these arrangements, they were recorded in risk assessments but as yet had not been recorded as agreed Best Interests decisions for each person affected, through a formal Best Interests process. The registered manager confirmed these processes would be put in place for those few affected.