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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.

Before care started, health, risks, communication, routines, relationships, goals, preferences and future wishes were explored with the person and/or family. The provider’s AI tool (Magic Notes) captured the consultation, allowing the assessor to focus fully on the person and explore physical needs alongside what mattered to their independence, dignity and wellbeing.

Assessment continued once care began. The AI tool analysed staff’s visit records, helping identify repeated observations, changing needs and whether recorded outcomes were being achieved. This informed reviews with people and relatives, alongside service reviews, quality assurance and direct feedback. Findings were human-reviewed before changes were made.This resulted in increasingly individualised care, with changing needs, preferences and risks identified and acted upon rather than waiting for routine reassessment.

People told us they were involved in initial and on-going assessments. One person said “I`ve been involved in the decision making from the beginning and they came out to discuss a care plan and introduced us to 2 carers” and another said, “They introduced a new carer last week and [they] came round this week. It`s good to be introduced rather than someone just turning up don’t you think? Yes, I am totally involved.” Records were person-centred and reflected what was important to the person.

The provider ensured each person was assessed so they would know their needs before providing care. Initial assessments were comprehensive and clear covering all aspects of the person and the care they required. Care plans were developed from the initial assessment.

Before care began, the team looked at care worker availability and routine. They then negotiated a time that worked for everyone. Once agreed, the care plan was set up on an application which the family could access.

The provider always 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. They worked to develop evidence-based good practice and standards.

For example, a person experienced health concerns included chemotherapy, chronic leg swelling and ulcers, pain, fluctuating mobility and episodes of breathlessness. Records showed the staff repeatedly identified deterioration and escalated this to the relevant healthcare professionals. As a result, medicines changes, wound care, compression support, nutrition, hydration and mobility aids were incorporated into the person’s day-to-day support. This led to an improved quality of life and clinical improvement.Relatives and professional feedback included positive comments on the responsiveness and detailed recording that supported coordinated decisions.

People were involved in developing their care plans. One person told us, “We have been with [Care agency] 2 months now. They came to the house to discuss [family member’s] care plan and introduced 2 carers and showed us the app that they use. They chat to me about my interests too.” Care plans were personalised to people’s individual needs and provided guidance to ensure their care was effective. The registered manager told us they were part of professional networks, and this helped to ensure they kept up to date with good practice.

Staff supported people with their nutrition and hydration needs and helped ensure people’s preferences were met. People and relatives told us, “They do [family member’s] meal preparation and involve [them] in decisions for what [they] want to eat”, “They make sure that they always have access to fresh food for [family member] now” and “[Family member] has Parkinson’s so [staff] know that [they] can only eat soft food.”

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.

People told us staff worked well together and communicated with them well to meet their needs. One person said, “I had a fall about 8 weeks ago and they encourage me to walk. They walk with me and walk behind me” and another said, “I’ve had viral problems and they have been coaxing me back to fitness and normality. They are very well trained, they made sure the carers had special training so that they can do my socks/stockings correctly. I get 3 all-female and one does my feet better than the district nurse!”

The provider had collaborated with another care company for several years. They had regular discussions with them, and shared relevant information. The registered manager told us, “We tend to have discussions over the phone to touch base. [Office staff] checks in with them once a quarter to see if they are aware of anything we are doing. For example, one person wanted a 30 mins visit in the evening. We can’t do that as we have a minimum of 1 hour. We signposted the family to [care company] for them to liaise and find the right service for them.”

The provider also worked well with the local authority in order to ensure people’s needs are met according to their needs. The registered manager told us, “We touch base with the social worker, updating them and liaising with them about a person and anything we might need to do.”

The provider always 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 told us the staff knew their health needs and met these at all times. Care records contained detailed information about people’s health conditions and how these might affect people. The staff actively promoted health and wellbeing rather than just focusing on tasks. Their vigilance and care meant they were able to identify changes to people’s health or concerns promptly and ensure these were addressed without delay.

Relatives felt the support their family members received had contributed to increased wellbeing and better health. For example, one relative said regular visits had improved their family member’s spirits, reduced [their] loneliness and encouraged them to attend social events and trips.

The provider liaised with relevant professionals to always ensure people received appropriate care and support. For example, a person had been diagnosed with brittle bones and were prescribed compression stockings. This condition causes bones to be extremely fragile and break easily, sometimes from little to no apparent force.

The registered manager contacted the district nurses to ask if they could provide training to the staff on the use of compression stockings on a person with brittle bones. They agreed to train the staff at the person’s home, showing how to do this with the person. This provided the staff with knowledge and the confidence to support the person safely and in line with their needs.

The staff made referrals to GPs, nurses and other healthcare professionals as necessary. Some people were escorted to appointments by care workers if this was part of their care package.

The provider monitored all people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves.

For example, one person came home from hospital with reduced mobility and high care needs. The service immediately organised for two staff to support them for every visit. Over time with support, the person’s condition improved and they were able to mobilise better. This meant they were gradually able to reduce the support to one care worker.

Another person required 172 care hours per month because of poor health. The staff recognised the person required a lot of support in all areas of their care. They made sure the person was eating and drinking and assessed them week by week. The registered manager told us, “After 3 full weeks, [person] was managing more independently and with encouragement, was able to dress [themselves]. We allowed [them] to pace [themselves] and improve slowly and surely.” This resulted in a marked reduction of their care to 24 care hours per month.

The provider had developed an outcome-monitoring system that extended beyond scheduled reviews. This tool analysed visit logs, eMARs and care information, helping managers identify repeated observations, changing needs and whether intended outcomes were being achieved. Human oversight was retained before action was taken.

The analysis highlighted patterns promptly, enabling managers to identify people potentially requiring closer review rather than relying on isolated visit notes.The provider said, “This oversight has led to tangible change. Wider digital auditing resulted in approximately 300 needs, tasks or risk records being amended or updated following human verification, reducing the likelihood of staff working from outdated guidance.”

There was evidence of regular reviews and action being taken immediately following any changes to people’s health needs. The service worked closely with healthcare professionals who knew people well and followed their advice to help meet people’s changing needs.

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment.

People confirmed they were consulted in all areas of their care and support and were given choice. All the people we spoke with indicated the staff were respectful of their choices at all times.

The provider was meeting the requirements of the Mental Capacity Act 2005 (MCA). People told us staff asked for their consent and involved them in decisions about their care and support. They said their choices were respected.

The staff were well informed of the principles of the MCA. They told us they always sought consent before supporting people.