Caremark (Wokingham and Bracknell)

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.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulations in relation to person-centred care, need for consent and safe care and treatment.

This service scored 38 (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 service had not checked people’s care and support was meeting their needs and preferences effectively. People’s care documentation had not always been monitored to ensure it remained up to date and accurately reflected their current needs. For example, there was no information recorded about specific medical diagnoses, or the associated risks in relation to long term medical conditions.

Assessments of need did not consider the full range of people’s diverse needs and were not always up to date for staff to understand people’s current needs. For example, people’s care planning contained information which was not always relevant to them. There was conflicting information about people’s nutritional needs, and conflicting information around moving and handling.

Wellbeing and communication needs were not sufficiently assessed. For example, the service supported a person with communication needs. There was no information to explain why the person had difficulty communicating, and how staff should support them with their communication needs.

For another person, the care records stated to ‘educate family members and client of risks of blood thinning medication.’ There was no information on what the risks were, and what information staff should inform the person/family about or if the family had been involved.

Care records did not evidence people were involved in their assessments. For example, care records included generic guidance which was not person-specific and therefore we were not assured people’s individual needs been appropriately assessed to maximise their care and treatment.

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

Care records did not always include information to support staff relating to people’s specific communication needs, care and treatment and care notes lacked clarity.

Clear information was not recorded on whether or not people were at risk of choking, how to support them and how weight was to be monitored. For one person, their speech and language therapy (SaLT) information had not been uploaded to their care records.

Care records did not contain sufficient detail in for staff to support people, promote and monitor their health and well-being. The service did not provide guidance to staff how to ensure food was prepared in accordance with International Dysphagia Diet Standardisation Initiative (IDDSI) guidance. For one person within the care records, there was no information about swallowing issues, the need for level 1 thickener and the risk around swallowing and choking linked to medicines. This did not support the safe care and treatment of the person and placed them at potential risk of harm from choking.

The provider did not always work well across teams and services to support people.

People told us the service supported with an increase in weekend calls and social workers have supported people with arranging their care.

Staff told us they were not informed in advance when they were supporting a new person. Staff read information to support people in their own time and information was not always uploaded to people’s care records.

Professionals told us they reminded the service to communicate effectively with them. People’s care records and assessments were not always comprehensive. Therefore we could not be assured information shared with others would enable people to receive care in line with their needs.

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

People were not encouraged and supported to make healthier choices to help promote and maintain their health and wellbeing, as there was limited evidence they were involved within their care planning.
 

Records did not always show how people were being supported to improve their health and well-being as any recommendations from healthcare professionals were not always reflected within people’s care plans and risk assessments.

We were not assured the service planned and delivered care and treatment with people which could impact on their well-being and potential risk of harm.

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. This meant there was a risk people may not receive consistently good outcomes.

The registered manager told us only care workers who could communicate in a person’s preferred language would attend care visits for one person. However, this was not documented within the person’s care records. Daily notes documented that staff were refused entry to the property because they could not communicate with the person. This was not reported to the office and happened on multiple occasions.

The service had not updated care records when informed of concerns by staff. Care records and notes did not provide clear information for staff to support people safely.

The registered manager told us they had mitigated the risk to a person by providing them with support by 2 members of staff. However, there was no evidence this person was supported by 2 members of staff, within the care notes. Care notes documented how staff struggled to support the person alone.

For two people who were at risk of developing pressure sores, there was no guidance about the risk, what prescribed cream was to be applied nor what the cream was. Daily notes documented that cream was applied, but did not specify where, and for one person where they had a sore on their body, staff documented a cream was applied. However, there no further information or follow up in order to monitor and improve outcomes.

Care records did not always include information on support to be provided in line with diagnosed medical conditions. This meant there was ineffective monitoring of people’s wellbeing and quality of life outcomes.

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

The registered manager did not ensure capacity assessments were carried out in line with the requirements of the Mental Capacity Act 2005 and associated code of practice. The registered manager did not ensure the principles of Mental Capacity Act 2005 (MCA) were fully understood and promoted so that people’s rights were recognised, protected, and upheld when giving consent and making decisions about their care.

People’s capacity to make decisions was not clearly documented within their care records.

People’s capacity assessments did not include guidance on how to specifically gain consent and were not decision specific. There was conflicting information recorded and there was no record of additional support provided to people with communication needs. This meant there was a risk staff may not know how to support people’s decision making appropriately to ensure they received safe care.

Multiple people’s care records included the same information in relation to communication needs and therefore the records were not person specific to support staff in obtaining consent. Whilst some people’s care records stated they were to be asked for consent before supporting with personal care and repositioning, the care notes did not evidence consent was obtained.