Archived: The Chase

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 Requires Improvement. 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 regulation in relation to safe care and treatment and consent

This service scored 29 (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.

Although the quality of risk assessment and care planning had improvement, there were still significant gaps or inconsistencies which placed people at risk of harm as the information was not clear for staff. For example, 1 person had recently fallen, and the outcome of the investigation was that their care plan would be updated with measures to prevent this from happening again. However this had not been undertaken and their care plans continued to detail the person as not having had a fall. Other people were at greater risk because of certain medications, such as those flammable creams for people who smoked and blood thinning medications which increased the risk of internal bleeding if a person was to fall. However these risks were not documented with how staff should minimise these, and care plans did not reflect all risks to people posed by their health and care needs. There was a lack of evidence that people were involved in the planning and reviewing of their care.

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.

Best practice guidance was not always consistently followed to ensure people’s safety and to enable them to enjoy the best possible quality of life. This included inconsistent application of dementia guidance to ensure the building was suitable for people’s diverse sensory needs. A number of bedroom doors had no signage or visual information such as photograph to help people who may be disorientated navigate. Some rooms had speckled flooring which is not in line with guidance and could cause confusion or falls. Where high contrast furniture or bedding was assessed as requirement to help people navigate their environment, this was not always in place.

Guidance for safe management of medications was not being followed. Where controlled drugs were being given which have a greater risk of toxicity, these needed to be witnessed by two appropriately competent staff to ensure they were being given safely. There were not always the staff in place particularly at night to do this. We observed one staff member had signed for a medication despite only being told verbally by a colleague that they had administered this, and having no way of confirming this. The risks of missing time sensitive medications such as those prescribed Parkinsons were not well understood. Although prescribed to be given at a certain time for 1 person, a staff member told us they might give them up to an hour later. This was despite this presenting a risk of rapid deterioration and tremors.

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

There were not sufficient numbers of suitably trained or competent staff available to ensure people’s assessed care needs would be met, and we saw staffing systems had not supported delivery of person centred or effective care. Although staff spoke positively of their teams, we identified delays in care, unsafe practices and that people were not being supported to achieve the things that mattered to them.

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

Where people had assessed health and care needs, it was not consistently clear how these were being safely met to support people in living healthily. For example a significant number of people were at risk of malnutrition and dehydration, however their care notes showed significant periods of time between offered drinks or food. There was no evidence that snacks were being offered despite the importance of supporting frequent nutrition and hydration. People being cared for in bed were at greater risk of social isolation, however we identified 2 people who had no recorded social activity of 1:1 time with staff during the previous month beyond routine care tasks. This significantly increased the risk of poor mental wellbeing and isolation.

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

Some improvements had been made to how risks to people were monitored, however systems remained ineffective at ensuring this was always the case. Certain people were assessed as requiring to be weighed on a weekly basis due to their risk of malnutrition, however we saw there had recently been gaps of up to 5 weeks between people being weighed. Furthermore, where people were at risk of malnutrition or hydration we saw long gaps between people being offered food and drink particularly when they woke up. One person was refusing to eat or drink, however when they declined a meal it was not recorded that staff were offering alternatives such as snacks to encourage them to do so.

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

The service did not consistently apply the Mental Capacity Act, and restrictions made on people did not always demonstrate how they had been reached or that they were in their best interest. For example where people were being given medication covertly, the capacity assessment was made based on their capacity to accept medication rather than to refuse it. Where medications were being given in this way, no advice had been sought from the GP on if they would be safe or effective if given this way to justify why this decision would be in their best interest.

Restrictions such as people who smoked having lighters taken from them by staff were made with an appropriate capacity assessment, and one person had bed rails fitted prior to a capacity assessment being made which was a form of restraint. Where capacity assessments had been undertaken these were not always consistent, for example 1 person was described varyingly as having capacity and not having capacity use a call bell to summon assistance. The outcomes of these assessments were not always followed, and 1 person had been handed time sensitive and high-risk medications when leaving the service to visit a friend despite being assessed as not having capacity to do so.