Continuity Health Care Services PVT Limited

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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

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.

This is the first assessment for this service. This key question has been rated requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

This service scored 42 (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’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

The provider did not always ensure people’s needs were assessed and recorded in a way which supported effective care delivery. Initial assessments were completed; however, a delay in completing care records and risk assessments to aid staff to support people safely meant care delivery was implemented before important information and essential documentation were in place. This resulted in staff not always having the guidance they needed to understand people’s needs, preferences, or risks. In some cases, assessments were not updated when people’s needs changed, meaning care plans did not consistently reflect the current level of support required. This limited the provider’s ability to deliver personalised, effective care and increased the risk of inconsistent practice.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

The provider did not always ensure care delivered was informed by current evidence‑based guidance and best practice. Care plans and risk assessments did not consistently reflect up‑to‑date clinical information relevant to people’s individual needs. In several cases, staff did not have clear, practical guidance on how to apply evidence‑based approaches within a home‑care setting, leading to variation in how care was delivered.

Where people had specific health conditions, such as pressure care or skin integrity risks, the information available to staff lacked the detail needed to ensure care was delivered safely and in line with recognised standards. Additionally, records used to monitor wound care and catheter care, such as repositioning charts, body maps and fluid intake charts, were not consistently completed by staff. This meant the provider could not be assured people’s clinical needs were being monitored effectively or deterioration would be identified in a timely way. Furthermore, a lack of oversight by the registered manager meant relevant actions or updates were missed, reducing the provider’s ability to ensure care and treatment were delivered in line with best practice. Therefore, increasing the risk of potential harm to people.

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

The provider did not always ensure staff, teams and external services worked together effectively to support people’s care. Information sharing between staff and other professionals, such as district nurses, GPs and therapists, was inconsistent, meaning important updates were not always communicated in a timely way. Care records did not always reflect the most recent professional advice, and staff were not consistently informed when changes to people’s health needs or treatment plans occurred.

Concerns were raised by district nursing teams due to recommendations not being followed, which resulted in poor progress and deterioration in the health of people. These gaps in communication and joint working created risks to continuity of care and increased the likelihood of staff delivering support which was not aligned with current guidance from other agencies. As a result, the provider could not be assured people consistently received coordinated, well‑integrated care.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

The provider did not always support people to live healthier lives in a consistent or proactive way within their own homes. Although some information about people’s health needs was recorded, staff did not always have clear guidance on how to encourage healthier lifestyle choices or support people to manage long‑term conditions effectively. Care plans did not always include up‑to‑date advice from health professionals, meaning staff were not consistently guided by current recommendations. As a result, the provider could not be assured people were receiving the support they needed to maintain or improve their health and wellbeing at home.

However, a few people praised staff for encouraging and supporting independence wherever possible. This included supporting people to walk short distances with an aid or helping them to wash and dress while still promoting their independence.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The service did not have effective systems to monitor people’s health, wellbeing or care outcomes, and this placed people at risk of avoidable harm. Staff were not consistently recording key information such as changes in mobility, nutrition, skin integrity or emotional wellbeing, and leaders did not have reliable oversight of people’s day‑to‑day needs. Where concerns were identified, these were not routinely escalated or acted upon, and there was little evidence monitoring informed care planning or risk management.

For example, there was ineffective systems or processes in place to monitor, review, or improve clinical outcomes for people. There was no reliable oversight of people’s health needs, and clinical risks were not consistently identified or acted upon. As a result, deterioration in people’s conditions were not sufficiently monitored. Several people experienced avoidable hospital admissions due to poor monitoring and ineffective management of pressure care and skin integrity issues. This demonstrated a failure to ensure people received safe, proactive care and that the provider was able to drive improvements in clinical outcomes

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

Mental capacity assessments and best‑interest records did not always follow the principles of the Mental Capacity Act (MCA). For example, some assessments lacked clear evidence of the decision being assessed, did not demonstrate all practicable steps had been taken to support the person to make their own decision, or did not show who had been involved in best‑interest decision‑making. This meant the provider could not be assured decisions made on behalf of people who may lack capacity were lawful, person‑centred or in line with statutory requirements. However, people and their relatives told us staff gained consent before providing support. Staff had completed MCA training and were able to describe how they sought consent during day‑to‑day care.