Tapton Grove

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 good. At this assessment the rating has changed to Inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes..The service was in breach of legal regulation in relation to need for consent as service were not established and operated effectively to deliver treatment or care with the individual’s consent.

This service scored 33 (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 consistently check and discuss people’s health, care, wellbeing and communication needs with them.Pre-admission assessments were not easily available and staff could not locate them at the time of our assessment. Following the assessment, leaders informed us that they had managed to locate these documents on the digital systems and in archives. However, they were not readily accessible and this undermined safe and effective care planning. People told us they were not fully confident that their individual needs had been appropriately reviewed or understood. This was compounded by the lack of a stable and consistent staff team. Staff told us they found it difficult to fully understand and stay updated on people’s needs because care records were not always thorough or current, handovers lacked sufficient detail, and frequent movement between units, particularly by newer or agency staff, meant staff could not build familiarity with people’s often complex needs. One staff said, “We can access resident care plans and assessments through the system, but very often do not have lots of time to view these. We are very often moved in our working areas so our input into documentation is limited”.People’s communication needs were taken into account, but these were not consistently reviewed or updated. Without regular reassessment, there was a risk that communication methods or tools were no longer reflective of people's evolving needs or preferences.Most of the assessments we reviewed required further work to ensure they were comprehensive and covered all relevant aspects of health, care, wellbeing and communication. In some cases, assessments had not been updated since October of the previous year, and key information was outdated. This meant staff did not have access to reliable or current information to guide effective care delivery, and people may not have been receiving support aligned to their present needs.

People were not always told about current good practice that was relevant to their care, nor were they meaningfully involved in how this was reflected in their care plans. Some people told us they had not contributed to updates in their care planning, and others said they were unsure whether reviews had even taken place. This limited their ability to understand or engage with care decisions based on current guidance. For example, individuals subject to Community Treatment Orders reported not being given clear explanations of the legal conditions in place, despite their significant impact. Additionally, gaps in record-keeping and inconsistent staff presence meant people had few opportunities to discuss or personalise their care in line with recognised best practice.

The provider did not consistently ensure effective collaboration across teams and services to support people’s needs. Staff reported being regularly redeployed between units, which they felt hindered their ability to understand residents’ complex needs and build consistent relationships. People also expressed dissatisfaction with this approach. Care records were often incomplete or not up to date, and the handover process was not always effective, particularly impacting agency and newer staff who struggled to keep pace with changing needs. This fragmented communication limited the ability to share comprehensive assessments and coordinate care effectively when people moved between different parts of the service.

The service did not always support people to live healthier lives or reduce their future need for care. While referrals were made to professionals such as dietitians and speech and language therapists (SALT) when needed, day-to-day support to promote healthy living was inconsistent. Staff told us that people had limited access to healthy eating options. Although management said this was due to personal preferences, we did not see enough proactive support to encourage healthier choices, especially for those at higher risk due to being significantly overweight.There was some evidence of positive outcomes where specialist input was followed. For example, one person who was significantly underweight had gained weight with help from the dietitian and staff. Efforts to promote wellbeing through activity were also limited. While activities like walks and outings were available, people told us they were often cancelled and only ran during weekday hours. This reduced opportunities for people to stay active and engaged. There were also missed opportunities to support people with personal hygiene, with gaps in care records resulting in some people appearing neglected, posing a risk to both physical health and dignity.

The provider did not consistently monitor people’s care and treatment to support continuous improvement or ensure positive outcomes.Care plans were not always up to date or detailed enough to reflect people’s current needs and goals. Daily records were often incomplete, making it difficult to track progress or identify where changes were needed.For example, one person receiving support for substance misuse was not being offered regular drug and alcohol testing, which limited the ability to monitor progress or manage risk effectively. Another person who wanted to live independently did not have a clear, step-by-step plan in place to help them work towards this goal.This lack of meaningful monitoring meant opportunities to improve care and support outcomes were often missed.

The provider did not consistently inform people of their rights around consent or ensure that consent was obtained before care and treatment were delivered.There was no evidence that people had been asked for their consent to the care and support provided. Some individuals could not recall being asked, and there were no records to show that consent discussions had taken place. This made it unclear whether people’s views and preferences had been taken into account during care planning.Staff did not prioritise helping people understand what they were consenting to, and there was limited evidence of person-centred decision-making. The service did not operate in line with the requirements of the Mental Capacity Act 2005. People’s capacity to make decisions was not routinely assessed, and there was a lack of clear documentation to support decisions made on behalf of those who lacked capacity.We reviewed documentation for several people where staff had confirmed individuals lacked capacity, including those receiving covert medication. However, no formal capacity assessments or best interest decisions were recorded. Although the provider acknowledged these gaps, no action had been taken to address them at the time of the inspection.In addition, restrictions were in place for multiple people, such as being prevented from leaving the premises, without appropriate Deprivation of Liberty Safeguards (DoLS) authorisations. Where DoLS were in place, they had not always been reviewed in line with changes in people’s needs.As a result, people were at risk of receiving care and treatment without their consent, or without proper legal authority, which could amount to a breach of their rights under the Mental Capacity Act.