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• 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 outstanding.
This meant people’s outcomes were consistently better than expected compared to similar services. People’s feedback described it as exceptional and distinctive.
 

This service scored 88 (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 always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them.
Assessments considered the whole person, including their health conditions, risks, history, relationships, routines, interests, strengths and desired outcomes. Care plans showed how this information was translated into practical guidance so staff could provide personalised support.

Staff demonstrated an exceptional understanding of the person's holistic needs and continually adapted support to promote their wellbeing, independence and safety. Through careful observation and professional curiosity, staff identified environmental factors that were adversely affecting both the person and those providing care minimising disruption.
When significant environmental concerns were identified within the property, staff took a proactive lead in coordinating support, liaising with family members living at a distance and other relevant organisations to ensure the issues were addressed promptly and effectively. Throughout this period, staff recognised the additional impact that disruption could have due to the person's cognitive impairment and tailored their approach accordingly.

Staff invested considerable time in providing reassurance, maintaining familiar routines and supporting the person to understand and manage the changes taking place around them. Their approach reflected a deep understanding of the individual's emotional, psychological and practical needs. As a result, risks to health and wellbeing were significantly reduced, the person's home environment became safer, and they were able to continue living in the place they knew and valued while maintaining important aspects of their daily life.
This demonstrated not only effective assessment of need but also highly coordinated, person-centred practice that placed the person's wishes, wellbeing and long-term outcomes at the centre of decision-making minimising the risk of hospital admission and enabling the person to continue to live a life they desired. The actions taken went beyond addressing immediate concerns and resulted in sustained improvements to the person's quality of life and living environment.Assessments addressed mobility, medicines, nutrition, hydration, skin integrity, emotional wellbeing, dementia and environmental safety. We viewed numerous examples and heard feedback from people who were supported and involved to structure, create and review their own care packages to ensure they fitted around their assessed needs including whether people’s wishes to remain at home, maintain their independence and continue activities that mattered to them.
Assessments led to positive and, in some cases, life-changing outcomes. Staff used their understanding of people’s identity and abilities to look beyond their diagnosis. One person living with dementia was supported in a way that recognised their former professional role and demonstrated abilities that had not previously been recognised, helping them return home from hospital. People’s care also involved families and relevant professionals, including GPs, occupational therapists, dietitians, mental health services and fire safety services. The services unique and adaptive form of assessment enables people to return home in circumstances which may have delayed their discharge and effectively supporting a more person led and effective recovery in an environment which was familiar and comforting to the person.
 

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.
The provider planned and delivered people’s care and treatment with them, including what was important and mattered to them. Staff followed current guidance and professional advice to meet people’s individual needs. Care plans contained guidance about nutrition, hydration, diabetes, medicines, skin integrity, mobility, dementia and fire safety, and records showed staff followed this guidance during visits.
Professional advice was translated into people’s day-to-day care. Staff worked with occupational therapists, dietitians, GPs, mental health teams and other professionals and used specialist equipment, environmental adaptations and individual guidance to support people safely at home.
 

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.
A professional described staff as responsive and collaborative and said the management team held detailed discussions about what would work well for people and then acted on this. Another professional said staff contacted them promptly when they had concerns about a person whose care they shared.
Records showed that staff escalated falls, wounds, health deterioration and medicines concerns to the appropriate professionals. Families received updates through telephone calls, emails, remote meetings and the provider’s electronic system. Relatives said communication worked well and that they were involved in reviews and discussions about changes in people’s health and support. This coordinated approach helped people receive timely care and remain safely in their own homes.
 

The provider always supported people to manage their health and wellbeing to fully maximise their independence, choice and control.
Staff demonstrated an exceptional commitment to helping people live healthier and more independent lives by tailoring support around individual strengths, aspirations and health needs. Their approach went beyond meeting immediate care requirements and focused on preventing deterioration, improving wellbeing and enabling people to achieve outcomes that mattered to them.
People experienced significant and sustained improvements in their physical and emotional health as a result of this personalised support. One person was supported to develop a greater understanding of healthy eating, build practical cooking skills and make informed lifestyle choices. As a result, they lost weight, felt healthier and achieved positive health outcomes which were recognised by healthcare professionals. These improvements reduced the risks associated with future health complications and increased the person's confidence in managing their own wellbeing.
Staff achieved particularly positive outcomes by building trusting relationships and adapting support to suit each person's circumstances and goals. People were supported at their own pace to overcome barriers that had previously affected their health, independence and quality of life. This included supporting individuals to improve the safety and condition of their home environment, develop personal care routines, access healthcare appointments, reconnect with family members, participate in community activities and build confidence in managing anxiety and low mood.
Staff demonstrated exceptional skill in balancing safety, wellbeing and independence. For example, one person living with progressive cognitive impairment was supported through a carefully planned and creative approach that addressed risks to their health and nutrition while preserving their autonomy and established lifestyle. By understanding the underlying causes of deterioration and adapting support around what mattered most to the person, staff improved nutrition, reduced health risks, enhanced emotional wellbeing and enabled the person to remain living safely in their own home. This avoided unnecessary restrictions and prevented a move away from a home and lifestyle that were important to them.
The provider worked proactively and collaboratively with families, healthcare professionals and community partners to improve outcomes for people. Staff consistently sought opportunities to promote healthier lives through support with nutrition, diabetes management, physical activity, emotional wellbeing, dementia-related distress, mobility and access to specialist equipment. Their preventative and person-centred approach resulted in people being healthier, more confident, more connected to their communities and better able to maintain their independence for longer, leading to a demonstrable improvement in their overall quality of life.
 

The provider used continuous monitoring, review and evaluation to ensure care remained responsive to people's changing needs and delivered meaningful improvements in health, wellbeing and quality of life. Rather than monitoring for compliance alone, leaders and staff used information from reviews, observations, medicines monitoring, incidents, quality assurance processes and direct feedback from people and their families to identify opportunities to improve outcomes and reduce future health risks.
Monitoring resulted in timely and significant changes to care arrangements when people's needs evolved. For example, one person's support increased from scheduled visits to live-in care after reviews and observations identified previously unseen risks between calls. The provider carefully matched the person with compatible care professionals, which reduced anxiety, promoted emotional wellbeing and significantly reduced behaviours that placed the person at risk. Another person's package of care was continuously adapted following bereavement, changes in mobility, falls, hospital admissions and progress towards personal goals. Support evolved alongside the person's circumstances, ensuring care remained effective, preventative and focused on achieving the best possible outcomes.
Staff demonstrated exceptional skill in using ongoing monitoring to understand the causes of deterioration and identify approaches that would improve people's longer-term health and independence. One person living with cognitive impairment and a life-limiting condition initially declined support. Through consistent review, observation and relationship-centred care, staff recognised that maintaining the person's identity, connections and sense of purpose was fundamental to improving their wellbeing. As health needs changed, staff identified concerns about nutrition and successfully explored why the person was eating less. Monitoring showed the person was more likely to eat and engage socially when spending time with trusted care professionals in community settings. Support was therefore redesigned around meaningful social opportunities that incorporated meals, companionship and activities linked to lifelong interests.
The impact was significant and sustained. The person's nutritional intake improved, reducing the risks associated with poor nutrition and further deterioration. They developed trusting relationships, became actively engaged with their support, maintained personal dignity and presentation, and remained socially connected despite the progression of complex health conditions. Their emotional wellbeing improved and they continued to participate in activities that reinforced their identity and independence. This personalised and preventative approach enabled the person to experience a better quality of life for longer and reduced the likelihood of avoidable health deterioration and more intensive health and social care interventions.
Positive outcomes extended beyond the individual. Family members described feeling reassured that their relative was safe, eating well, socially engaged and receiving support they willingly accepted. This reduced stress and anxiety for relatives and enabled them to maintain meaningful family relationships rather than primarily fulfilling caring roles. Across the service, reviews consistently evidenced improved mobility, safer home environments, healthier nutritional outcomes, reduced distress, greater independence and improved wellbeing, demonstrating that monitoring was effectively used to achieve measurable and lasting improvements in people's lives.
 

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment.
People and their relatives were involved in developing care plans and reviews. People signed service agreements, gave verbal consent before medicines support, and were offered choices about meals, personal care and daily activities. Staff understood consent was ongoing and described supporting people to retain choice while keeping them safe.
Where people might lack capacity for a specific decision, the provider completed best-interest records relating to areas such as medicines management, monitoring equipment and the signing of documents. These decisions considered identified risks, involved relatives and people close to the person, and frequently reflected the person’s wish to remain at home using the least restrictive approach.