St Johns Wood

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 83 (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 treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

The registered manager assessed people’s needs before care started and reviewed care plans every 3 to 6 months, or sooner if their needs changed.

People and their families participated in these reviews. People’s preferences, including cultural or religious needs, were discussed to ensure care was personalised. Relatives confirmed this. Comments from relatives included, “The manager comes out and does a home visit. [My relative] knows her,” and “Staff are really well matched to [my relative’s] personality.” Another relative told us, “[We are] all involved in care planning. The manager spent a long time going through [person’s] needs and carers were paired up to [person].”

Care records showed that managers and staff worked together with relatives to keep assessments up to date and relevant to people’s lives.

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.

Care was led and coordinated by qualified nurses with current clinical experience in the NHS. The registered manager, who is a registered nurse, ensured care planning reflected the latest clinical guidance and multidisciplinary input. This included liaising directly with hospital consultants, private GPs, and community specialists such as dietitians and physiotherapists to align home-based care with ongoing medical treatment.

The provider’s ethos centred on continuity, clinical safety, and personalisation. Each person’s care plan incorporated their medical history, treatment protocols, and goals for recovery or wellbeing. Digital systems were used to track vital signs, wound healing, and taking medicines in real time, helping staff respond promptly to changes in condition.

The provider embedded evidence-based practice through structured training and competency assessment. Staff completed a range of relevant training to help them provide high quality, safe care. Nurses undertook a range of specialist training to ensure they had the skills to provide nursing care.

Staff also completed dementia training, which included communication, understanding behaviour, person-centred care, safety, and care environments. The training included interactive scenarios and reflective exercises to reinforce learning and confidence in supporting people living with dementia.

Managers assessed staff competencies and provided regular supervision to ensure best practice was maintained. This ensured that care was clinically sound and aligned with national standards.

In addition, the provider developed a bespoke, evidence-based training programme that helped carers and professionals apply clinically informed strategies to improve communication, empathy, and wellbeing for people living with dementia. By sharing this evidence-based resource with other organisations, the provider promoted best practice beyond its own service.

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.

The provider worked alongside other healthcare professionals such as GPs, consultants, and therapists to ensure people were getting the right care and support.

A staff member told us, “We speak with the GPs and other professionals when needed.” There were effective systems for staff to communicate with each other and share information. A staff member commented, “We have daily communication and handovers between shifts.”

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.

Staff communicated regularly with GPs and other healthcare professionals to coordinate care and ensure continuity.

Staff encouraged people to remain active and independent where it was safe to do so. A person we spoke to said, “It’s been life changing for me. Due to my disability and my mobility, I can’t walk by myself I use crutches. [Staff] support me, and I go out with them every day.” A relative commented, “Having the carers has improved [my relative’s] health all round. It relaxes [them]. [They] know [they’re] well looked after.”

The provider’s self-created dementia training programme helped care workers apply evidence-based strategies that improved communication, empathy, and wellbeing for people living with dementia. By sharing this resource widely, the provider promoted healthier lives beyond its own service.

The provider routinely 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.

Managers reviewed care plans regularly with people and their relatives. They updated these when people’s needs changed. Managers supported people to identify personal goals. Staff monitored people’s progress and recorded this in care records and daily logs.

The provider used an electronic monitoring system to record and oversee people’s care in real time. During the assessment, the registered manager demonstrated how staff entered care notes, medication records, and wellbeing observations directly into the system during visits. This information was instantly visible to managers, who could identify missed tasks or early signs of risk, such as changes in skin condition, diet, or mobility.

The system included built-in alerts for time-critical activities such as medicine administration and low medicine stock levels. Managers and nurses could access live dashboards to check compliance, review visit logs, and address any issues immediately. Families also had access to relevant updates, which promoted transparency and reassurance.

This real-time oversight helped prevent gaps in care and supported early intervention if a person’s needs changed. It also meant that any issues identified through audits or daily checks could be addressed promptly, ensuring consistent, safe, and coordinated care.

Relatives told us that people’s wellbeing had improved because of the care provided. One said, “So many things have improved [my relative’s] quality of life. I don’t worry about [my relative] at all now. I have 100% peace of mind.”

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

Relatives confirmed this and 1 relative told us there were “No problems” with staff respecting their family member’s choices.

People were involved in reviews of their care. Records were updates to reflect changes in their needs or preferences. Staff adapted their approach when a person declined care at a particular time. Training and supervision reinforced staff understanding of consent and decision-making, supporting safe, person-centred care. Staff were able to describe supporting people with consent, including listening to them, contacting relevant professionals, and carrying out mental capacity assessments to make best-interest decisions when required.

The provider worked with relatives and professionals to make decisions in people’s best interests when they lacked the mental capacity to make these decisions.