Care and Support Service - Monica Wills 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 remained good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

This service scored 75 (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 carried out comprehensive assessments before people began using the service to ensure their individual needs, preferences and goals could be met. Assessments involved people, their relatives and relevant professionals and were used to develop personalised care plans. One person told us, “They took time to get to know me before I moved in. We talked about what was important to me, how I liked things done and what support I needed. I felt involved from the start.”

Care plans reflected people's health, wellbeing, communication needs, preferences and risks and were regularly reviewed and updated when needs changed. Relatives spoke positively about the provider's thorough approach. One relative said, “They really took the time to understand Mum as a person. The care plan reflects her needs and preferences, and we are always involved if anything needs to change.”

People benefited from a workforce whose training and development were tailored to meet their individual needs. The service identified and provided any additional training required to ensure staff had the knowledge, skills and competence to support people safely and effectively. This helped ensure people received personalised care that was responsive, well planned and delivered by staff with a clear understanding of their individual circumstances, preferences and support needs.

The provider planned and delivered care around what mattered most to people. Assessments and care plans reflected people's health needs, preferences, routines and goals, and were regularly reviewed to ensure support remained effective and responsive. One person told us, “I am involved in the planning of my care. Everything is written in my care plan which the carers check each time they visit.”

Staff followed clear, up-to-date guidance and worked closely with healthcare professionals to support people safely and respond to changes in their needs. A relative told us, “When Mum's health changes, the staff know exactly what to do. They keep us informed and work closely with the right professionals to make sure she gets the support she needs.”

Records were detailed and regularly reviewed, enabling staff to identify and respond quickly to changes in people's wellbeing. Staff understood people's dietary and hydration needs and took proactive steps to promote good health outcomes. For example, where staff identified risks associated with poor fluid intake, they increased the availability of hydration stations, expanded the range of drinks offered to provide greater choice and monitored people's fluid intake more closely. This enabled staff to identify patterns, respond promptly to concerns and encourage people to maintain adequate hydration in ways that reflected their preferences. Staff also supported people to maintain important relationships with family and friends. This helped ensure people received consistent, person-centred care that reflected their individual needs, preferences and current best practice.

The provider worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff told us they worked together well as a team. Regular handover discussions ensured information was passed between them. Handover notes were detailed and recorded information such as how people were and any concerns. Short daily meetings were held and provided an opportunity for information to be shared about people’s health and wellbeing and any specific priorities.

Staff engaged well with other agencies to ensure people's treatment needs were met. Documents we reviewed indicated communication from the team around people’s needs was effective.

The provider supported people to live healthier lives. Care plans promoted independence, wellbeing and meaningful activity, helping people stay active and engaged. Staff supported people to attend healthcare appointments, take part in activities they enjoyed, such as walks or gym sessions, and maintain relationships, which improved their physical and emotional wellbeing.

Staff encouraged and supported people to eat and drink well. They monitored risks to nutrition and hydration and acted where needed, helping people maintain a balanced diet and avoid deterioration. Staff told us they supported 1 person to drink more to reduce their risk of dehydration, and this improved their skin integrity. A person told us, “I’ve had problems with my skin, but staff are on it and it is improving day by day.

Staff involved health professionals promptly when concerns arose. This ensured people received timely care and treatment, helping them maintain their health, prevent avoidable decline and experience better overall wellbeing.

The provider continuously monitored outcomes through regular care reviews, audits, daily records and feedback from people and relatives. Managers reviewed care plans, medicines, incidents and concerns to identify areas for improvement, promote good practice and reduce risks. Learning from audits and incidents was shared with staff to support continuous improvement and positive outcomes for people.

Staff achieved positive outcomes by responding promptly to changes in people's needs and working with relevant professionals when required. For example, staff provided enhanced support to a person living with dementia through increased monitoring, personalised wellbeing support and referrals to specialist services. People were also supported to maintain their nutrition, hydration, independence and involvement in their community through tailored care and regular wellbeing checks.

People and relatives spoke positively about the outcomes achieved. One resident told us, “I can still live the life I want with the support I get here.” A relative said, “They are very proactive and always keep us informed if anything changes.” Another relative commented, “The continuity works well,” and described the service as “a very good set up.” These comments demonstrated the provider's commitment to delivering responsive care that supported people to maintain their wellbeing and quality of life.

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

Staff knew how to seek consent and had followed the Mental Capacity Act (MCA)when people did not have capacity to make decisions for themselves. This included involving the people closest to them and to make sure decisions were made in their best interest.

Mental capacity assessments had been completed, and the manager and team leads were liaising with the placing authority to ensure Court of Protection applications had been made, as deemed necessary. Staff had a good understanding of the MCA and supported people to be involved in their care. Where there were conditions imposed, these were incorporated into the care plan for the individual and kept under review.