Head Office

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

This is the first assessment for this newly registered service. This key question has been rated good.

This meant people’s needs were met through good organisation and delivery.

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 did not always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

The information recorded in people’s care files was not always accurate and individual. For example, a female was referred to as ‘he’ throughout their assessment. Another person’s assessment stated that staff needed to complete exercises before they started their personal care, however there was no further guidance available for staff showing what these exercises entailed.

We received mixed feedback from people and relatives about their involvement in the review process. A relative said, “It’s so long ago when they started and I’m not aware we’ve had any reviews since then.”

However, other people and their relatives confirmed reviews had taken place. Staff felt they were aware of people’s individual needs and preferences and delivered care to people aligned with these.

The provider understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

The provider told us there were systems in place to monitor and review care. We saw these systems were followed when needed. The provider, where possible, tried to ensure people received a consistent staff team to ensure the care they received was consistent.

The provider did not always ensure there was a proactive and positive learning culture.

The provider told us they had a system in place that recorded when incidents had occurred, they told us they used these incidents to make improvements to the service and ensured lessons were learnt. We viewed these systems and saw incidents were recorded, such as; when vehicles had broken down, when there was staff sickness and when there was a lack of access to the office. The action taken in response to the incidents was also recorded. However, there was no record to show consideration had been given to ensure similar incidents would not reoccur. This showed improvements were needed to the learning culture at the service.

The provider made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support.

People and relatives felt they were involved with their care, and they were listened to when needed.

There was a system in place to ensure complaints were responded to in line with the provider’s own policy and procedure.

The provider did not always ensure there was a proactive and positive learning culture.

The provider told us they had a system in place that recorded when incidents had occurred, they told us they used these incidents to make improvements to the service and ensured lessons were learnt. We viewed these systems and saw incidents were recorded, such as; when vehicles had broken down, when there was staff sickness and when there was a lack of access to the office. The action taken in response to the incidents was also recorded. However, there was no record to show consideration had been given to ensure similar incidents would not reoccur. This showed improvements were needed to the learning culture at the service.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The provider was aware of inequalities people receiving support may face. There were systems in place to consider and act on people’s experiences in care, if needed.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

People and relatives raised no concerns with the planning of end-of-life care.

The provider confirmed they were not supporting anyone who was currently receiving end of life care. As part of the assessment process people’s thoughts and preferences had been considered and documented.