Care Navigation

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.

This is the first assessment for this service. This key question has been rated 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 made sure people’s care and support was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff used a range of recognised clinical measures to ensure people’s needs were understood. Assessments included physical, health, wellbeing and communication needs. The home care manager was in the process of reviewing all care records with people or their relatives to ensure individual needs continued to be accurately reflected. Staff told us they were able to access care plans and risk assessments and usually found these to be useful.

Although, relatives told us staff knew how to meet people’s needs, we received mixed feedback about initial contact from the service. Two relatives said there had been a delay in sharing information with them or their family member. This had been resolved, but they felt the communication when they first came into contact with the service could have been better.

People’s communication needs were assessed and documented in care records. Changes were shared with staff in meetings and electronically. This helped ensure staff provided effective support which was individualised.

The provider 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 and current evidence-based good practice and standards.

The provider used current and relevant clinical tools to monitor and review people’s needs. For example, assessments of nutritional needs, pressure care requirements and a screening tool regarding falls.

Information about people’s nutrition and hydration needs and preferences was clearly recorded. Assessments reflected current guidance, and included personalised details about likes and dislikes, food preparation, dining preferences and risks. One person followed a vegetarian diet, and there was clear information for staff about how to meet their needs and preferences.

Care records described how staff should support people to eat and drink when they wanted. For example, by ensuring drinks and snacks were available when staff were not present.

Staff received training in subjects such as food safety, diabetes care and oral health management. This helped ensure staff used up to date approaches to deliver support in line with best practice to meet people’s needs.
 

The provider usually 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 could access information about people’s needs. One staff member told us, “Care plans are detailed. They give information about client’s needs and wants. They help us know more about the problems and how to help the person.”

Information was shared between services to ensure co-ordination and continuity of care. For example, when people used different services or during hospital admissions.

Overall, feedback from professionals was positive regarding working in partnership with Care Navigation. One professional said, “The team are highly collaborative and responsive, working closely with us to ensure people are kept safe and supported appropriately.” However another professional stated, “Staff having a clearer understanding of how our service works and how we can work collaboratively would help ensure a more integrated and effective approach to supporting individuals.”
 

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

Records showed that people accessed external professionals, and staff encouraged people to live healthier lives, whilst respecting their choices. This included choices relating to activities, routines or food. The provider reviewed records with people or their relatives to ensure information remained relevant and up to date.

Staff told us they usually knew people well, and so they noticed if someone’s health or wellbeing was deteriorating. Staff supported some people with their health appointments.

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

Clinical monitoring tools were in place, and these were regularly reviewed. There was evidence that actions had been taken to address concerns or changes when these arose. One relative told us, “[Name] says her legs and feet have never been so well cared for. The staff are very thorough.”

The home care management team were reviewing care records to ensure people’s health and wellbeing was monitored and met expectations. They requested feedback from people and their relatives and carried out spot checks to observe staff competence.
 

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

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. Staff received training in the MCA and understood the importance of ensuring that people fully understood what they were consenting to and the importance of obtaining consent when supporting people.

Staff told us they gave people time and presented information in different ways to ensure people understood their choices and were able to consent or make decisions. One staff member said, “We always give people choices and decisions wherever we can. It's their home. We can't just come in and change things and do what we want to do. We help them to have choices about what to watch on TV, what food to eat and so on.”

The provider consulted with others when decisions needed to be made in a person’s best interest because they did not have capacity. For example, an assessment had been carried out with a person, their family and a social worker to agree how staff would provide support including personal care and administering medicines.