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• 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 inspection for this newly registered service. This key question has been rated requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

This service scored 50 (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 did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

People and relatives expressed mixed views regarding their awareness and involvement with their care plan. Their comments included, “I don’t know if I have a care plan”; “My relative has no major care plan” and “We have a care plan, but I don’t think it’s been revised.”

The registered manager told us that they worked closely with people and their relatives to ensure care is kept up to date and current to each person's needs and preferences. Care reviews occurred every 6 to 12 months, or more frequently if necessary. Care staff communicated with relatives before and after their visits and shared any feedback or concerns to management.

People's communication needs were assessed.

The provider did not always ensure good practice guidance was followed to ensure people received effective care. For example, National Institute for Health and Care Excellence (NICE) guidance was not always followed in relation to medicine management.

Although the principles of the best practice guidance, such as ‘Right support, right care, right culture” were broadly being followed, we found examples were care records lacked sufficient detail, and aspects of staff training required strengthening. These shortfalls limited the service’s ability to consistently demonstrate effective and person-centred support.

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 supported people to access other healthcare professionals, when required, to meet their individual needs. Although the provider had not developed hospital passports for people; these are accessible summary documents about people's heath and care needs that support people when accessing health and care services.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

For autistic people and people with a learning disability, care records did not consistently show whether they had received an annual health check. This lack of recorded information limited the provider’s ability to clearly demonstrate proactive monitoring of people’s wider health needs. We found no evidence that this had negatively affected anyone’s health.

Staff supported people appropriately with their nutrition and hydration needs.

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and

consistent, or that they met both clinical expectations and the expectations of people themselves.

The registered manager and nominated individual told us they gathered feedback on the care provided and were also involved in the delivery of the care, when required. However, records did not evidence that reviews of care included discussions with people and relatives and whether people were satisfied with their care outcomes. We received feedback from one person who told us they did not feel they received the care they required. We shared this feedback with the management team and after our inspection they told us they were working with this person to review their care.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

A person told us staff did not always respect their choices. We shared this feedback with the management team who told us about the work they were doing with staff to ensure they were appropriately supporting this person.

The provider understood how to apply the requirements of the Mental Capacity Act (MCA). We found a record of a best interest decision had not been completed, but this was put in place after it was discussed with the management team.