Stonewood Complex Care

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.

This is the first assessment for this newly registered service. This key question has been rated good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

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’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them regularly and updated them in response to people’s changing needs.

Managers assessed people’s needs before accepting them into the service. Before providing care, the service developed detailed care and treatment plans with input from people, their families and relevant health professionals. Staff received training specific to people’s treatment needs and equipment. This included shadowing staff in people’s existing settings, such as hospitals, where required.

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.

Care and treatment were delivered in line with the best available evidence, recognised standards and current guidance. Staff understood the potential implications of the care they provided and sought guidance when required. For example, staff identified and recorded an unusual change in the colour of a person’s urine. Correct processes were followed and recorded.

Registered nurses maintained their professional registrations and continued their professional development. They shared best practice within the service. One health care professional told us the service was, “Responsive, knowledgeable, approachable, honest, the clinical expertise within the team is good and varied…and they are professionals that know their clinical skills”.

Managers and staff introduced improvements when new evidence or learning became available. The provider ensured staff received training whenever new treatments or updated equipment were introduced for a person.

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.

Staff told us they worked effectively as a team to deliver safe and consistent care. There was regular communication between staff, people, families and external professionals. One professional told us, “They are easy to contact and provide information when it is requested.” Another professional spoke positively about the service overall but raised a concern about an over‑reliance on one staff member, which they felt could undermine the wider arrangements in place if not addressed. This was raised with the provider who will explore this further.

Nurses, managers and office staff held daily meetings where they shared information. The wider team accessed relevant information through electronic systems and telephone contact, where appropriate. Community staff also shared information between shifts through face‑to‑face discussions and used handover tools located in people’s homes, alongside the electronic records. Everyone we spoke with described communication within the organisation as effective.

The provider worked with local partners to expand communication methods and had requested access to partner systems to further enhance information sharing. Systems were in place to ensure staff shared relevant information about people appropriately with other services and healthcare professionals.

The provider 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.

Staff supported people with their physical health and care needs, along with their wider wellbeing. Staff understood people’s medical needs, including required interventions, observations and expected ranges that indicated health status. When staff identified concerns, they worked proactively with healthcare professionals to ensure people received timely advice and treatment. This had resulted in reduced hospital admissions for one person, and specialist support from an NHS trust for another person.

Staff worked closely with other professionals, including physiotherapists and occupational therapists. They followed therapy programmes and ensured these were implemented consistently to support people’s ongoing health and mobility.

Due to the consistent and stable staff teams, staff had a strong understanding of the people they supported and how their conditions affected them. This holistic knowledge enabled staff to recognise subtle changes, cues or behaviours that indicated how a person was feeling or when something was unusual for them. Staff escalated any signs of deterioration in people’s health or presentation promptly to ensure appropriate monitoring, support or intervention.

Staff encouraged people to take part in meaningful activities both in their homes and in the community. They supported people to remain active, maintain or improve skills and engage in activities that reflected their interests.

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

People were supported to live the lives they chose. Staff discussed and recorded people’s goals, wishes and aspirations within their care plans and clearly set out how they would support individuals to achieve these. We saw positive examples of people developing new skills and increasing their independence. One staff member told us, “Our clients have realistic but achievable goals to reach. Our carers often support our clients with them and allow them to live a rich life and have all their holistic needs met. An example is how multiple of our clients have been able to go on holiday thanks to the support of Stonewood”.

The provider had effective systems in place to monitor and improve outcomes for people. These included surveys, audits, spot checks and regular reviews. Reviews involved people and all relevant parties. Managers used these systems to identify what was working well and where improvements were needed.

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

People and staff told us consent was sought before care or treatment was provided. Staff understood when and to whom they should report any changes relating to consent or capacity. Records showed staff used appropriate care approaches and strategies to encourage people’s engagement with care and treatment.

People’s records contained signed consent forms that covered areas such as consent to care and treatment. Where people lacked the capacity to consent, staff recorded mental capacity assessments and documented best‑interest decisions. The provider was working with its electronic recording system to ensure capacity assessments clearly identified the practitioner who completed them. This was required as capacity assessments were most often completed by external medical professionals.