Archived: 142 Petts Hill Care Home

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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

We identified a breach of regulation relating to the gaining of people’s consent. We found staff were not following best practice guidance when assessing people’s capacity and were placing restrictions on people, which were not appropriate. The processes in place did not ensure people had the best outcomes and were supported to lead healthier lives.

This service scored 25 (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 make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them. Records showed a lack of involvement from people and relatives in the assessments and review of people’s health and care needs which was mainly completed by staff. Therefore, we could not be assured that positive outcomes were achieved for people’s care, treatment and support in accordance with their specific needs and requirements.

Care plans and risk assessments were not up to date or reviewed. The providers’ process for assessing people’s needs was ineffective, there were no audits in place to monitor people’s outcomes. This meant that people supported did not receive the best outcomes in their support needs.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards. The service did not always plan and deliver person-centred care and treatment. Care records were not detailed or reviewed, a person required support from a professional team. When we asked the provider told us, “We have monthly meetings to discuss person’s mental health needs,” we asked for details of these meetings and related outcomes these could not be provided on the day of our inspection, therefore we were not assured that people’s needs were met. A staff member we spoke with was unclear how best to support the person if they faced challenges with their mental health, this meant that the person was not being supported according to their needs.

The provider did not work well across teams and services to support people. They did not share their assessment of people’s needs when moving between different services.

The guidance for staff in people’s care plans was not always up to date, and accurate. There was a risk that people could receive inappropriate care which did not meet their current care needs. Where there were identified risks and a care plan, there was little information to show how this was monitored to check people were improving. For example, interventions when a person had an increase in the frequency of behaviours caused by agitation or distress. There was no monitoring of these incidents so that concerns could be escalated and advice sought from external professionals to agree changes to minimise risks.

The provider told us a person received regular visits from the community Mental Health Team, we asked for this information to be shown to us on the day of our inspection, the information could not be found. This meant that information and guidance on how best to support the person during times of distress was not available to staff to support the person effectively.

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

Staff told us a person had monthly visits from local GP Community Nurse and support from the local Community Psychiatric Nurse (CPN) we saw no evidence of these visits in the person’s support plan or care records. We asked the provider to share these documents with us; we did not receive them. This meant that we were not assured the person was receiving the right support in accordance with professional meetings and in their best interest.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

There was no effective process in place to monitor the outcomes for people, the provider had not requested feedback from people to assess if people were happy with the outcome of their care. Care plans had not been monitored to check they included accurate information and there was no process to monitor outcomes. This meant that outcomes for people were not up to date reviewed and therefore individual support needs could not be met effectively.

The provider did not tell people about their rights around consent or respected these when delivering care and treatment.

People were not always supported in line with the Mental Capacity Act 2005 to ensure decisions had been made in people’s best interests or in the least restrictive way. For example, the provider had made decisions about people’s care without consulting all the relevant people who should be involved. This had led to restrictions on people’s freedoms and human right and some decisions had exposed people to the risk of abuse.

The provider had not worked within the Mental Capacity Act 2005 (MCA), they had not followed best practice guidance. People were at risk of being restricted without following the required process. For example, a person was restricted from using the kitchen after 21.00pm at night due to fire risks as the person was known to smoke in their bedroom. There was no evidence that the person had been involved in the process. By not following best practice, staff had placed people at risk of being restricted and their decisions not being respected. Staff explained they had sent the Deprivation of Liberty (DoLS) referral to the local authority however when asked for written confirmation this was not shared with us.

We also asked for the Mental Capacity policy and related training, we have not received this.

People were not always supported in line with the Mental Capacity Act 2005 to ensure decisions had been made in people’s best interests or in the least restrictive way. For example, the provider had made decisions about people’s care without consulting all the relevant people who should be involved. This had led to restrictions on people’s freedoms and human right and some decisions had exposed people to the risk of abuse.