Care and Support Service - Monica Wills House

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has changed to outstanding. This meant services were tailored to meet the needs of individuals and delivered to ensure flexibility, choice and continuity of care.

This service scored 93 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were at the heart of care and support, including those with complex and changing needs. Staff described supporting a person experiencing mental health difficulties who required additional support to manage anxiety and maintain their wellbeing at home. Working closely with healthcare professionals and commissioners, staff developed consistent approaches tailored to the person's needs, enabling them to continue living successfully at Monica Wills House. Staff spoke passionately about providing equitable support for everyone, with 1 member of staff telling us, “We do not segregate here; we give our best to every single person.”

Support was shaped around what mattered most to people. Through detailed conversations with people and their relatives, staff developed a clear understanding of individual histories, aspirations, relationships, routines and preferences. Care plans reflected this information and guided staff in delivering support that was meaningful and personalised. One staff member said, “All the information about people is in the care plan. We get to know what they like and how they like it done.”

People were encouraged to maintain independence, develop skills and participate in activities that gave them a sense of purpose and achievement. People developed and crafted their own beer and ran a weekly bar, taking ownership of a valued community initiative while building social, practical and organisational skills. Others were supported to access local cafés, pursue personal interests and share their life experiences through talks about their backgrounds and contributions to society, helping to promote confidence, identity and self-worth.

People told us this approach had a significant impact on their lives. One person said, “Coming here has been the beginning of a different life rather than the end of it. With the support given, I can be myself. It's certainly a new lease of life.”

People's spiritual wellbeing was recognised as an important part of their overall quality of life. Access to a chaplain, a reflection room and on-site religious services enabled people to practise their faith in ways that were meaningful to them. Staff also adapted support when required; for example, 1 person who was unable to attend church because of declining health was supported to access services remotely.

People and relatives consistently told us they were involved in decisions about care and support. One person said, “Care plan was discussed in detail.” A relative told us, “Care plan was done in our house originally, she was very involved and had a trial run in the care home.” This demonstrated a strong commitment to ensuring people remained in control of decisions affecting their lives.

The provider generally coordinated care well and worked effectively with a range of health and social care professionals to support people's needs and maintain continuity of care. There was strong evidence of partnership working with GPs, district nurses, physiotherapists, occupational therapists, the Falls Team, local authority teams and specialist services. Staff escalated concerns promptly when people's health needs changed and worked collaboratively with professionals to review care, equipment and treatment arrangements.

The provider worked proactively with the Falls Team to improve people's mobility and independence. One person benefited from an innovative approach where the Activities Lead continued to support them with tailored exercises alongside their prescribed physiotherapy programme. As a result, the person not only maintained their strength and mobility but significantly improved their confidence and overall wellbeing. This support enabled them to lead a full and active life, making regular use of the service's facilities, including the gym and bowling activities, and participating in swimming sessions within the local community. The person experienced greater independence, social inclusion and improved physical health, achieving outcomes that were important to them and enhancing their quality of life.

The provider had also introduced a new medication ordering system to ensure medicines were requested and received in a timely way. This reduced the risk of delays or gaps in medication supplies and helped improve continuity of care for people who relied on regular medicines.

Emergency Travel File and clear referral information supported safe transitions between services and ensured important information was shared when people accessed external healthcare services. Most people experienced continuity of care and told us that seeing familiar staff helped them feel safe and reassured. The provider promoted consistency through team-based rotas and shadowing arrangements. However, a small number of relatives reported occasional changes in staff and delays which affected continuity of care. These concerns were not typical of the service, and when issues were identified the registered manager took action to address them. Whilst continuity could not always be fully maintained, the provider generally worked effectively with partners and professionals to coordinate care and support positive outcomes for people.

The provider ensured people received information in ways that met their individual needs and preferences. People's communication requirements were assessed as part of the initial assessment process and clearly documented within care plans. These records provided staff with guidance on preferred methods of communication, any sensory impairments, cognitive needs, communication aids, and steps staff should take to reduce barriers to understanding.

Care plans contained personalised information to help staff communicate effectively with people, including those living with dementia, hearing impairments, learning disabilities, or complex health conditions. Staff used a range of approaches, such as visual prompts, written information, repetition, and involving relatives or advocates where appropriate, to support people to understand information and make informed decisions about their care.

Reviews were undertaken face-to-face, enabling staff to check people's understanding, identify changes in communication needs, and adjust support accordingly. Detailed care planning and continuity of care through consistent staff teams helped ensure staff recognised both verbal and non-verbal communication cues and responded appropriately.

Staff demonstrated a good understanding of people's individual communication needs. One staff member told us, "Everyone communicates differently, so we check care plans and adapt our approach to suit the person. Some people prefer information written down, while others respond better to pictures or taking things step by step." Another said, "We get to know people's routines and how they express themselves, especially if they find verbal communication difficult, so we can make sure they are involved in decisions about their care."

This personalised approach helped people access information relevant to their care, express their views and preferences, and remain involved in decisions affecting their daily lives.

The provider sought and acted on the views of people, relatives and staff to help shape and improve the service. Regular resident meetings and surveys gave people opportunities to share feedback, discuss matters important to them and contribute ideas about the running of the service. Feedback was generally positive, and people were encouraged to express their views during regular reviews of their care, helping to ensure support remained responsive to their needs and preferences.

People were provided with a service user guide which clearly explained how to raise concerns or make a complaint. Records showed complaints were listened to, investigated and acted upon. Relatives told us concerns they had raised had been resolved through improved communication and responsiveness from the management team. One person said, “They always ask for my opinion and listen to what I have to say.” These systems helped ensure people felt involved, heard and able to influence both their care and the service they received.

The provider ensured people could access the care, support and treatment they needed when they needed it. Staff acted as effective advocates, supporting people to access health and social care services, ensuring referrals were made promptly and addressing barriers to access. The management team demonstrated a strong understanding of local health and social care pathways and worked closely with specialist professionals and partner agencies to achieve positive outcomes. Equality, diversity and inclusion policies were embedded throughout the service, helping to ensure people were treated fairly and received support tailored to their individual needs.

The service was particularly effective at identifying and overcoming barriers for people with a wide range of needs. Staff recognised that equitable access required personalised approaches that reflected each person's strengths, abilities, aspirations and preferred communication methods.

The service demonstrated a strong commitment to supporting neurodiverse people who lived and worked within the service. A range of reasonable adjustments were implemented according to individual needs, including accessible documentation, Access to Work support, 1-to-1 support where recommended, Dragon speech-recognition software, adapted Outlook settings, timers and speech-to-text technology. These adjustments enabled people to communicate effectively, work confidently and participate fully in daily life and work.

The provider also embraced innovative approaches to promote involvement and independence. For example, the Nourish system enabled people using the service to contribute to their own care records, ensuring their views remained central to care planning and decision-making and promoting greater choice and control over their support.

People and their relatives consistently described positive experiences and told us staff were quick to respond when concerns or changes in need were identified. One relative said, “If anything changes, they are quick to get the right people involved and keep us informed.” Staff worked collaboratively with external professionals to ensure support remained accessible, coordinated and effective. As a result, people experienced positive outcomes and were enabled to live fulfilling lives regardless of their physical, sensory, cognitive or social support needs. The provider's inclusive culture, innovative practice and strong partnership working promoted equitable access and positive outcomes for everyone using the service.

The provider was committed to ensuring people experienced equitable outcomes regardless of their needs, abilities or circumstances. Staff delivered inclusive, person-centred support and proactively removed barriers to participation, enabling people to lead meaningful and fulfilling lives. For example, people living with dementia were supported to take part in the resident-led beer crafting project according to their individual abilities and interests. Some people were involved in recipe discussions and tasting sessions, while others helped with labelling, packaging, promoting the product, or sharing memories of brewing and pubs. Staff adapted activities to ensure everyone could contribute in a meaningful way, helping people maintain skills, build confidence, strengthen relationships and retain a sense of purpose. The Innovation Lead explained, "We meet each other where we are."

People were supported in ways that reflected their individual communication, sensory, cultural and spiritual needs. People with sight loss were actively involved in co-designing accessible printed materials, ensuring information was available in formats that worked for them. People were also enabled to practise their faith in ways that reflected their preferences and circumstances, including accessing services remotely when required. The provider demonstrated a proactive approach to supporting people's wellbeing through the employment of a dedicated Pastoral Care Coordinator. This role exceeded what is typically seen in similar services, where spiritual and pastoral support is often provided through external community or faith representatives. Based at the service, the Pastoral Care Coordinator provided an additional source of support for people, staff and managers, helping to promote emotional wellbeing, reduce social isolation and ensure wellbeing initiatives were embedded into day-to-day practice. Their presence enabled timely, personalised support and contributed to a culture where people's holistic needs were recognised and addressed.

The provider demonstrated a proactive approach to supporting people's wellbeing through the employment of a dedicated Pastoral Care Coordinator. Based at the service, the Pastoral Care Coordinator provided an additional source of support for people, staff and managers, helping to promote emotional wellbeing, reduce social isolation and ensure wellbeing initiatives were embedded into day-to-day practice. Their presence enabled timely, personalised support and contributed to a culture where people's holistic needs were recognised and addressed.

The Pastoral Care Coordinator told us, “We use worship through song because it helps people connect with themselves and others and reminds them of who they are. We work hard to make everything as inclusive as possible. We hold welcome meetings for new people, take communion to those who are unable to attend services, and celebrate key events from different faiths, including Diwali, so everyone feels valued and included.” This personalised approach helped people maintain important aspects of their identity, fostered a sense of belonging and ensured people could participate in meaningful spiritual and cultural experiences regardless of their individual needs or circumstances.

People and relatives consistently spoke positively about the inclusive culture. One person told us, "I am treated with dignity and respect and encouraged to do as much as I can for myself." A relative said, "They really take the time to understand the person and make sure support is right for them." This personalised and equitable approach enabled people to maintain independence, achieve positive outcomes and participate fully in community life regardless of their individual needs or circumstances.

People were supported to plan for important life changes and future wishes, enabling them to make informed decisions about their care and support, including at the end of their life. Regular conversations took place to understand people's preferences, aspirations and goals, ensuring these were reflected in care planning. The provider used a recognised advance care planning tool where appropriate to support discussions about end-of-life care. When people required end-of-life support, staff worked collaboratively with healthcare professionals and families to ensure care was delivered in line with the person's wishes, providing compassionate, coordinated and dignified support. The provider worked closely with health services to ensure people received appropriate end-of-life care and support. An end-of-life comfort box was available, containing items such as sensory lighting and other comforting resources to help create a calm, personalised and dignified environment during this time. The provider also had access to respite beds for people whose needs deteriorated, with priority given to existing people to support continuity of care. Staff were able to continue supporting people across other trust care settings where appropriate, helping to maintain familiar relationships and provide reassurance during what could be a challenging and emotional period for people and their families.