Exceptional Care At Home (Barnet)

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• 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 service. This key question has been rated good.This meant people’s needs were met through good organisation and delivery.

This service scored 75 (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 made sure people were at the centre of their care and treatment choices and worked in partnership with them to respond to any relevant changes in needs.

People’s care plans and risk assessments were thorough, person‑centred and written in the first person, reflecting what was important to them and their preferences. Care plans included clear information about medicines, contacts and consent, and were updated regularly, including when people’s needs changed, so care remained appropriate.

Staff recorded detailed and individualised daily notes which reflected the care provided and informed updates to care planning. People had access to a copy of their care plan in their home and were involved in discussions about their care, which supported a consistent and personalised approach to care delivery. A person’s relative said, “We were involved as a family. We said what we wanted and (the person) is getting the care (they) need.”

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.

Care coordinators assessed people’s needs, recorded them, and communicated them clearly to staff and other professionals. They worked with care workers and external professionals to keep care appropriate when people’s needs changed. They managed transitions between services, including hospital discharge, in a coordinated way, and they arranged care before people returned home so support continued without interruption.

Staff shared information effectively across teams, which supported consistent care and reduced the need for people to repeat information. This supported continuity of care, as reflected in feedback from a relative, who said, “There is a folder. Communication is good.”

Staff adapted care to reflect people’s choices and changing needs, ensuring care stayed responsive and consistent over time.

The provider supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

People were given information about their care when support first started. A person’s relative told us, “The manager came to the house and explained everything.” Care coordinators explained care plans and involved people and their relatives in conversations about what support was needed. Staff continued to explain things during visits, so people understood what their care involved. Care plans kept in people’s homes made information easy to access, current and shared quickly regarding any changes.

The provider could also make information more accessible if needed, such as producing easy-read documents or reading care plans aloud. Although there was no current need for these alternatives, they were ready to adapt to individual needs. However, some people and relatives said they were not always fully informed about care plan reviews or changes, showing that communication could still be improved.

The provider made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff involved people in decisions about their care and told them what had changed as a result.

The provider listened to people effectively. They held regular care plan reviews where people and their relatives could contribute to decisions about their care. People told us they felt involved and able to express their views, and concerns raised were listened to and acted on. The registered manager used feedback and complaints to make improvements and encouraged ongoing feedback through regular surveys every 3 months and direct communication. These arrangements supported people to be actively involved and influence their care. The registered manager told us complaints were addressed promptly, often on the same day. A relative told us that if they had a concern, “I would phone the office. Very responsive.”

The provider made sure that people could access the care, support and treatment they needed when they needed it.

The information reviewed showed care was delivered reliably. Visits happened as planned with no signs of missed or cut-short appointments. This matched what people using the service and their relatives told us. A relative said, “Time keeping is good and convenient for us.” Staff responded quickly when people’s needs changed, arranged extra support and raised concerns when necessary.

Care Coordinators made sure support continued smoothly. Care was provided on time and reliably. The provider had an out of hours monitoring team to pick up calls from 05.00pm to 09.00am.

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.

Care was provided in a dependable and consistent way. Staff adjusted support to suit each person’s needs, preferences and situation. A relative told us, “We have regular carers which is so important as (the person) has dementia.” Records showed care was delivered fairly and consistently.

Care plans considered individual needs, including communication and accessibility requirements, and information could be provided in different formats when needed. Most people had positive experiences, although some said communication was not always consistent, showing there is still room to improve and make everyone’s experience equally good.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including when their needs changed.

Staff worked with people and professionals to plan for changes in need, including arranging reassessments, additional support, and referrals when required. Staff coordinated planning for key transitions, such as hospital discharges, to ensure continuity of care and minimise disruption. A relative said, “They always ask how things are going.”

These arrangements supported people to receive appropriate care as their needs changed over time. However, planning was primarily focussed on responding to changes rather than anticipating longer‑term future needs. While staff had received training in end‑of‑life care, there was limited evidence of proactive future planning or advance discussions with people about their longer‑term preferences.