AA-I-Care - 35 Southwell

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 good.

This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

This service scored 71 (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.

People were supported to have consistent and effective care by staff and leaders. The provider had pre-admission assessment procedures to understand people’s needs and ensure they were able to meet them. People’s needs were comprehensively assessed and included consideration of their physical and mental health, sensory, social and communication needs. Assessments were regularly reviewed and updated to make sure the information was current, and care and support was meeting people’s needs and individual outcomes as expected. Tools were used to effectively support the assessment of people’s health and care needs, and those were used by staff with the right understanding and skills.

People and their relative told us they were involved in care planning and regular reviews. Comments included, “We have a care plan, that's up on the wall and we have regular reviews.”

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.

People’s care plans were developed holistically and included information and guidance from other professionals. Best practice guidance in relation to people’s specific support needs were understood and followed by staff. Staff recognised and responded promptly and adequately to people’s changing needs. Appropriate referrals to external services such as physiotherapy, occupational therapy or the community mental health team were made in a timely manner to make sure people’s needs were met.For example, we reviewed a care plan for 1 person which included a detailed and positive behavioural support plan. Thishad been developed with the person, their relative and healthcare professionals on how to best support them toimprove their mental and physical wellbeing

People and relatives confirmed they received consistent support because the provider worked in collaboration with other services. One relative told us, “The manager contacted the frailty team and the occupational therapy team. Their recommendations are in the care plan, including the use of a hoist and a care plan for [my loved one’s health condition] affecting their mobility. All is incorporated in the plan, detailing how often [my loved one] should be encouraged to stand up or walk.”

People were supported to achieve optimum nutrition and hydration, and their care plans outlined their food and drink preferences. Systems were in place to monitor people's nutritional intake and weight, and risks associated with dehydration and malnutrition. Care plans identified the level of support people needed from staff to prevent malnutrition and dehydration and any specific diets or food allergies. One relative told us, “[Our loved one] has some food allergies so we have that all planned out. There are some special ready meals if we are stuck and a plan of meals for [our loved one].”

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 established effective systems and processes for referring people to external services and to maintain continuity of care. Plans for transition, referral and discharge considered people’s individual needs, circumstances, ongoing care arrangements and expected outcomes. This meant people’s care was effectively coordinated, to ensure they received timely and consistent support and treatment.

Staff worked with other health and social care partners to prevent or reduce the need for admissions to hospital. People were accompanied by staff to the healthcare appointments and when they needed hospitalisation. One person told us, “I’ve been poorly this year with a [health condition] so I haven’t been able to go out much. Finally, I have got an appointment and one of the managers will take me. They always take me to my appointments which is great. Hopefully I will be able to get out and about when I am treated.”

We received positive feedback from health and social care professionals about collaborative working. One professional told us, “The provider has shown good collaboration with externalprofessionals. For example, they worked with the diabetic nurse to develop a tailored meal plan to support the client’s diabetes management and have contacted the GP when necessary to address health concerns.”

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.

People were referred to and supported to access appointments with GP, dentist and other healthcare professionals when needed. One relative told us, “Staff take [my loved one] to the GP when [they] need to go.“ Staff effectively empowered and supported people to be involved in or manage their own health, care and wellbeing needs as much as possible. For example, staff supported 1 person to regularly attend a local gym, and another person had been actively encouraged to walk their pet dog.

The provider established effective systems and processes to ensure people’s day-to-day health and wellbeing needs were being met, and people experienced positive outcomes related to these needs. We received positive feedback from people and relatives about the support people received to manage their health and wellbeing and to enhance independence. Comments included, “[My loved one] decides about [their] day as much as [they] can, and [they] are very happy.”

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.

The provider established effective processes for monitoring the effectiveness of people’s care, treatment and support to continuously improve the service. People were asked about their goals and what they wished to achieve from the support provided. Staff worked with people to enable to them to achieve their goals and supported them to be as independent as possible whilst maintaining their safety.

Staff monitored people's health and welfare and reported any concerns to the management team. Where needed, a member of the management team would make referrals to health care professionals. The manager told us they worked very closely with people, their relatives and health and social care professionals to ensure positive outcomes for them. For example, they supported a person alongside the phlebotomy nurse with regular intravenous therapy.

The provider actively sought feedback from health and social care professionals and stakeholders as appropriate when monitoring individual outcomes. Health and social care professionals we contacted confirmed this. Comment included, “They have effectively managed complex family dynamics, responding promptly to concerns and working proactively to resolve issues.”

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

Staff had received training in the Mental Capacity Act (MCA) but did not fully understand or always follow the principles of a best interest process in accordance with legal requirements, when a person lacked capacity to consent to the arrangements for their care and treatment. Consent to care and treatment and subsequent best interest’s decisions had not always been obtained in line with legislation and guidance. We discussed this with the manager, and they took immediate action to rectify this.

People’s care plans contained information about their mental capacity and what support they required to make decisions. The management team and staff monitored people's mental capacity to ensure that they were able to make appropriate decisions, however this was not always effective. Principles of the MCA were not fully understood and followed in line with the MCA assessment process. Mental capacity assessments were not always completed where people did not have capacity. For example, we reviewed the care plan for 1 person who was deemed to have fluctuating mental capacity to make specific decisions. There was no mental capacity assessment or subsequent best interest decision completed for this person. This meant people’s human and legal rights were not always understood and respected.

People and their relatives told us they were involved in their care decisions and staff respected those decisions. People were able to make day to day decisions about their lives. For example, they were supported to choose what they would like to wear or how to spend their time as they wished.