Winners Trophy

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 registered 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.

People had care needs assessments in place however, some areas of risk had not been identified in the initial assessment or transferred to care plans and risk assessments. For example, one person told us a review had not taken place after their relative had been discharged from hospital. The relative had texted the information to the registered manager, so they had the information to communicate with staff, but they had not received an updated care plan or risk assessment. Upon reviewing the person’s care plan, there was no evidence to demonstrate the necessary changes had been made. However, the registered manager told us they were in the process of updating the information during the time of the inspection.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

We found the service did not always have evidence-based tools embedded into their care planning system. For example, two service users’ care plans did not have relevant guidance for staff to follow in relation to their diagnosed conditions which potentially placed people at harm because information was not available for staff to understand how to support people with their conditions. Whilst a very high risk ‘Waterlow’ score had been identified for one service user, ‘Waterlow’ is a tool to assess whether people are at risk of skin integrity issues, there was no information within the service user’s care plan to guide staff on how to manage this risk.

The provider did not always work well across teams and services to support people. We received mixed feedback from people and staff about teamwork within the service.

Some staff told us there were regular team meetings, however other staff told us they did not attend team meetings due to the nature of their working hours. A staff member told us they did not receive the support they needed to “feel like they belonged” to the service. Most relatives we spoke with told us the service had not supported them to make referrals to other agencies. However, one relative told us the service had completed referrals and had followed up on any concerns or issues with professionals on behalf of their relative. Team meetings were taking place, which was evidenced through meeting notes we reviewed as part of this inspection, and we saw evidence of reflective practice taking place when things went wrong. A local authority partner who had worked with the service told us; “My experience with the service has been really positive. They always kept in touch when things changed or if they were unsure, which reassured me because I knew the person was safe and being looked after. I could always get in touch with them and [Manager] always responded quickly to emails.”

The provider supported people to manage their health and well-being to live healthier lives. People provided positive feedback about how staff supported them to live healthy lives. For example, one relative told us, “The call times have been reduced from 2 calls per day to 1 because the staff saw [person] was managing well during the second call of the day. [Person] waits for them every day at the same time to come and help.” We saw evidence of a person being supported by staff to go out on regular walks to help maintain theirmobility and access the community. Staff were able to describe what they did to support people to live healthier lives. One staff member told us, “[Person] doesn’t like staying in, we go out at least 3-4 times a week so [person] can chat to different people, we go on the bus on regular trips and meals out. They also get lots of exercise because they don’t sleep very well.” A partner told us, “They worked really hard with a person who had a history of disengagement with services and got them to do things, so it was such a relief.”

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. We found people’s care plans and risk assessments did not always contain information to enable staff to monitor outcomes. For example, we found conflicting information between people’s care plans, risk assessments and medicine support plans and it wasn’t clear in some cases what information staff should follow. Therefore, staff may not be aware of how to manage and monitor people’s risks and outcomes. Staff did not always have access to evidence-based information on people’s diagnosed conditions which meant staff did not have all the relevant information to support people safely.

The service had an electronic application system to enable people to view records of care notes recorded by staff. However, people provided mixed feedback about being able to access these. Staff told us sometimes the electronic application system did not always work which meant they had to update the notes later in the day. The registered manager told us there had only been a few instances with the electronic application system not working and people were shown how to use the system when they started using the service. However, the registered manager had not considered any other option to record notes contemporaneously when the system was not working to ensure there was an effective way to document and monitor care delivery.

People told us they were not asked for regular feedback about the service; however, they could get in touch with the registered manager if they needed anything. One person told us, "I haven’t been given the opportunity to feedback formally.” Staff told us they did not get involved in gaining feedback from people using the service and would signpost them to the office. During the inspection, when we requested evidence of feedback received by the service, the provider did not send us any feedback they had gained from people, except for 1 online review which was posted in 2024.

Staff seemed to know people and their needs well but some information they provided about people was not represented in people’s care plans or risk assessments.

The provider had changed to a different electronic care planning system at the end of 2024 and told us they were still working on ensuring the system worked for the service but there had been some challenges with transferring people’s information over.

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

Processes to assess whether people had capacity to make specific decisions and to make best interest decisions on their behalf were not always in line with legislation and national guidelines. For example, one person had a mental capacity assessment which had been completed in November 2023 but had not been reviewed since this date which was not in line with best practice guidance. This meant the assessment may not have remained, relevant, proportionate and appropriate. Additionally, this person did not have a decision-specific mental capacity assessment in place. This again was not in line with national guidance as it referred to multiple decisions and contained no evidence of what key information had been shared with the person to test if they were able to understand, retain and weigh up the information for each decision being made. The same person had restrictions placed on them by the service without the appropriate legal powers such as Lasting Power of Attorney for Health and Care being in place or evidence of professional decision making. There was also conflicting information about whether the person had capacity or not within the mental capacity assessment. We found another person did not have a mental capacity assessment in place despite the person’s care planning documents stating they may lack capacity due to a diagnosed condition.

Some people had signed and agreed to their care plans but other had not. The registered manager told us they were looking at how they could gain consent from people in relation to their care plans as the electronic system did not have this option available. One staff member could not tell us what the mental capacity act was and how they should work in people’s best interests and told us; “I just follow the care plan for this.” Other staff members were able to provide a basic overview of the mental capacity act and working in people’s best interests but again told us they relied on information in people’s care plans.

However, people told us staff always asked for consent when providing care and support. Staff told us how they gained consent from people before supporting them with their personal care.