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.

People’s needs were assessed to ensure staff were able to meet these before the person moved to the supported living service. Care plans were developed from assessments and included communication, mobility, psychological and physical health care plans as well as guidance relating to different activities of daily living.

Information in care records considered the physical environment people lived in and any potential risks, to be able to effectively support the person in their own home.

Care plans were regularly reviewed to ensure they continued to reflect people’s needs. Staff told us they knew people well, but were also able to access care plans and risk assessments and found these to be useful. 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 people who were supported by Care Navigation were unable to be actively involved in planning or reviewing their care and support. Staff told us their family members or supporters were involved in regular reviews and any changes which were required.

Information about people’s nutrition and hydration needs and preferences was clearly recorded in care plans. This included guidance for staff about people’s likes and dislikes, how people communicated preferences and records of food and fluid intake.

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. Staff said they were confident in supporting people to manage their dietary needs and associated risks.
 

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 attended different activities or regarding their complex health needs.

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 relating to activities, routines or food.

Staff told us they usually knew people well, and so they noticed if someone’s health or wellbeing was deteriorating. Care records gave clear guidance stating, “[Name] is unable to verbally communicate when they are feeling unwell or in pain and may not show obvious signs of illness. For this reason, close observation is essential. Staff must monitor [Name’s] physical appearance, behaviour, and mood carefully each day and look for subtle signs that they may be unwell, uncomfortable, or in distress. These may include changes in sleep, appetite, facial expressions, posture, activity levels, or engagement with others…Early intervention is vital in preventing more serious health issues from developing.”

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.

There was evidence that staff monitored people’s health and wellbeing outcomes and related these to their quality of life. For example, by introducing new activities or taking different approaches to encourage people to engage in a range of tasks. One staff member told us, “Sometimes [Name] doesn’t want to do the activity that day, but we come back again and try another time.”

A care plan stated, “If [Name] refuses to eat or drink, staff must document this in detail, including the approaches and strategies they used to encourage...Staff should record which strategies were attempted, whether they were effective, and any relevant observations about [Name’s] responses.” This demonstrated how staff were supported to monitor and improve people’s care and outcomes.

The service requested feedback from people’s relatives and professionals 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.

Care plans clearly recorded how staff should give people time and present information in different ways to ensure people understood the choices and were able to consent or make decisions. For example, “It helps [Name]greatly when people approach her gently, speak clearly, and give her time to respond. Using her name, ensuring she can see the speaker, and using simple words and signs all support her understanding” and “During activities, help [Name] communicate needs in their own way and ensure they are included in decisions through small, clear choices.”