Archived: Social Care Solutions Limited (Northampton)

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 service. This key question has been rated 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. Staff did not always understand how to meet people’s current needs because people’s care plans and risk assessments were not up to date. This meant the provider had failed to have systems in place to ensure staff had all the up-to-date information they needed for people to received consistent care.

This service scored 33 (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 make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing, and communication needs with them.

People’s needs were assessed before they started using the service to ensure they could be appropriately supported. However, there was no formal process in place to assess people’s needs, as their needs changed or following a hospital admission.

The area manager told us care plans were assessed at least monthly. However, these reviews were not effective, and we found significant gaps in the completion. Records showed a lack of involvement from people and their relatives in the assessment and review of people’s needs, which was mainly completed by staff. We could not be assured that positive outcomes were being achieved for people’s needs.

People’s care plans and other records did not have all the information staff needed, to be able to meet people’s needs. For example, one person had been newly diagnosed with diabetes in 2024, there was no information in the care plan to guide staff on how to meet this person’s needs.

We found some conflicting information in peoples’ care records. For example, one care plan stated a person was able to eat and drink independently, however, other guidance said the person would overfill their mouth and was at risk of choking. The care plan lacked clarity for staff to be able to support them effectively.

The area manager told us they were moving to an electronic system for care planning, and care plans were being reviewed as part of the transfer. However, the provider had not ensured the required resources had been deployed to support the transfer, and there had been a lack of progress, due to staffing. Some care plans had not been reviewed, there was a note saying, ‘Under review going onto Nourish in 2025’.

There was a lack of adequate oversight from leaders in relation to assessing on-going needs and care planning. This meant people were at risk of not receiving safe care that met their needs.

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.

Some people in the service were at risk of pressure ulcers. Although staff used an evidence-based tool (Waterlow Risk Assessment) to assess and identify people’s risk of acquiring pressure ulcers, this was not reviewed regularly or accurately. For example, one person who had acquired pressure sores had not had their Waterlow risk assessment reviewed since 2024, and we found the original calculation was incorrect. People continued to be at risk of pressure ulcers as staff did not have the information they needed to prevent or manage people’s skin integrity.

People could not always be assured they would receive food that met their dietary needs. For example, one person who required a low sugar diet was regularly given foods with high levels of sugar and carbohydrate content. A relative told us a person had gone to the day centre with food that was insufficient for their needs. Another relative told us, “We were told meals would always be fresh, I don’t think that happens.” People who required close monitoring of their meals did not have a meal planner and there was a reliance on regular take-away meals or meals in cafes and restaurants.

Not all staff who prepared and served food had received training or competency checks in preparing food for people with specific needs such as soft foods to prevent choking. Following our feedback, the area manager told us they had introduced a competency check to ensure staff were aware of people’s specific dietary needs in response to speech and language guidance not always being followed.

People continued to be at risk of not having their dietary needs met as the provider did not have systems and processes, to ensure staff had the knowledge and skills to provide food and drink that met people’s needs.

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

It was evident through observations that staff knew the people they were supporting well, however, they did not have sufficient information available to them in care plans, risk assessments or handovers to understand how to mitigate all risks and reliably provide care that met people’s current needs.

We found not all staff had been assessed as competent to complete delegated clinical tasks in line with best practice guidance and there was a lack of oversight by the provider of these delegated tasks. For example, one person used non-invasive ventilation (NIV) at night, however, staff did not record key details of the administration of the NIV, and staff did not appear to understand what they were supposed to be checking. One member of staff referred to the NIV as the person’s oxygen, which was incorrect. The provider had not identified the monitoring tool used by staff was ineffective or that staff did not understand their role in checking the NIV at night.

Staff did not always understand how to meet people’s current needs. This meant the provider had failed to have systems in place to ensure staff had the information they needed, and people received consistent care.

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.

People were supported to access healthcare services. However, not all records we viewed evidenced people had accessed annual health checks or other services such as a dentist or optician. For example, several health action plans were blank and did not contain any information in relation to health appointments.

We observed some health concerns in relation to one person. We immediately escalated these concerns to a visiting manager who told us they would seek medical advice from the GP. On a follow up visit we found no record of medical advice being sought.
 

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.

Staff did not understand what goals or positive outcomes looked like, in line with legislation, national standards and evidence-based good practice guidance, to be able to support people to understand what they could achieve.

We could not see how people were being supported to identify and work towards long-term goals, beyond daily tasks, and there was a lack of involvement from people, and their relatives recorded, when people’s goals were assessed, reviewed, and monitored.

Staff were responsible for setting monthly goals; however, these were either not completed, or not aspirational with a view to improving outcomes. For example, people’s goals were cutting a cake, sorting furniture, or planning activities.

The provider did not have a robust approach to monitoring the effectiveness of people’s care, treatment, and support to continuously improve it.

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

People had mental capacity assessments and best interest meetings for individual decisions; however, these had not been completed in line with the Mental Capacity Act. For example, there was not always evidence of how people, their relatives or representatives had been involved, or how the wishes of people with communication needs had been considered.

Staff did not all demonstrate a good understanding of the Mental Capacity Act. For example, some staff did not understand the difference between Deprivation of Liberty Safeguards (DoLS) and the Court of Protection.