CJP Outreach Services Ltd

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 96 (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 always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them.

Care provision started only after a carefully planned and holistic assessment of the individual’s needs, preferences, and aspirations had been completed. This thorough and person-centred approach involved meaningful engagement with the person and their family, alongside close collaboration with health and social care professionals already involved in their support. Where appropriate, staff would work with previous care providers to ensure a thorough understanding of the person’s needs, and the support required to meet them effectively. The assessment was conducted at a pace that respected not just the person’s emotional wellbeing, but also that of their family members, ensuring they were at the heart of the assessment procedure but not overwhelmed by it and that everything needed was put in place before care started.

The assessment process included the introduction to the person and their family, of carefully selected staff, so they could choose who they would like to be part of their support team. A relative told us they felt they “led” the assessment process.

Care and support were continuously reviewed and adapted to remain responsive to the person’s evolving needs. Any changes were implemented promptly, ensuring the support provided remained effective in making sure people experienced the best possible outcomes.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

The provider always worked well across teams and services to support people. They shared changes in people’s physical and emotional health promptly with appropriate health and social care professionals to make sure people benefitted from a collaborative and inclusive approach.

An example of this outstanding approach was when staff had sought the opinions and expertise of professionals involved in 1 person’s care to try to identify the cause of a change in their behaviour. As part of a best interest process staff shared full and detailed information about what was happening with the person with a range of health and social care professionals and fully considered their advice to try to establish the reason for the person’s change in behaviour. This exceptionally collaborative approach considered a multitude of possible factors including, for example, pain which the person could not communicate and therefore helped the provider to eliminate some issues and concentrate on resolving other factors which was effective in restoring the person’s wellbeing.

The provider actively and consistently involved multi-disciplinary teams in people’s care and support. A member of staff told us, “We have regular multi-team meetings for [person] as their needs are so complex and are always changing. We work alongside their GP, learning disability team, dietitian, social worker and family to come up with the best outcomes."

The provider always supported people to manage their health and wellbeing to fully maximise their independence, choice and control.

The provider worked collaboratively and persistently to make sure people were supported to maximise their health and therefore their quality of life. An example of this was a person who had a physical condition which impacted, not only their physical health, but also heavily restricted their lifestyle. Although the person’s condition had been dismissed on multiple occasions by hospital teams, staff continued to advocate for them, with full co-operation from their family, until hospital treatment was agreed during which staff maintained 24-hour presence to support the person. This intervention resulted in the person enjoying better health and a more fulfilling lifestyle.

One person was fully supported with their goal to lose weight and improve their fitness with staff supporting them to attend groups, source and cook healthy recipes and engage in fitness activities.

When a person presented as being unwell and had changes in their behaviour, staff looked at a wide range of factors which may have contributed to this and set out a plan of actions to address each one. This included changes in diet, staffing, weather and routines. A health professional fed back to staff that their “list of suggested strategies with measures looks comprehensive and excellent.”

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 provider had effective systems and processes in place to ensure leaders were always up to date with changes to people’s clinical or quality of life outcomes

Each person had a personal development and support plan which included a section titled ‘What do I want to achieve’. The person’s aspirations were listed along with details about what staff needed to do to support the person to achieve their goal. This included any related risk assessments, possible adjustments to their living environment and advised staff, where appropriate, to work with the person at their own speed. Progress indicators were recorded and monitored for each of the person’s aspirations and staff were given information about how to record and demonstrate the person’s progress.

An example of this was a person being supported to access community settings. Consideration was given to several factors which might affect the person’s experience. For example, identifying appropriate venues, how to make the journey feel safe and enjoyable and how to empower the person to communicate their choices and feelings during the experience. Indicators of their progress included their willingness to get out of the car, their interaction with the setting and whether they showed signs of enjoying and feeling comfortable during the experience.

Where people had set long term goals and aspirations, a plan was put in place detailing the steps required to support them to be successful. Outcomes of each step were monitored to make sure the plan was right for the person.

The provider always carefully explained to people what their rights around consent were, made sure they fully understood them and always fully respected these when delivering person-centred care and treatment.

Processes for assessing people’s capacity to make decisions about their care were carefully and robustly assessed and used to inform the best interest decision making process. The provider made sure that all aspects of the person’s circumstances were reviewed to inform the process. The person’s history, abilities, ability to understand the decision being made and communication skills were considered along with detailed input from family, care staff and professionals involved in the person’s care. Staff included the person in the process by using their preferred form of communication, giving the person time to make a response and recorded any verbal or nonverbal responses. The least restrictive options for supporting the person were documented.

We saw an example of an exceptionally robust best interest process for a person who required anaesthetic for a medical procedure. The best interest meeting included the specialist involved, the anaesthetist, the learning disability nurse, a representative from the GP surgery and the person’s relative. All options were considered and a very detailed plan of action developed to support the person in preparing for, undergoing and recovering from the procedure.

One relative told us about how staff consulted fully with their family member who had difficulty with communication. They said, “Staff know this and make sure [person] is as empowered as possible to communicate and be fully understood. [Person] is never ever overlooked.”

Capacity and consent support plans were entirely person centred and detailed how staff should support the person to make decisions and how the person might communicate their consent or lack of it. Support plans instructed staff to respect the person’s indication of not consenting in that moment.

Staff demonstrated a good understanding of the mental capacity act and were involved in the best interest decision process. Staff’s understanding of the mental capacity act and consent issues was assessed through regular competence checks.