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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

This is the first assessment for this service. This key question has been rated requires improvement. This meant services were not planned or delivered in ways that met people’s needs.

This service scored 54 (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 were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

There were no effective systems in place to make sure people, and their relatives were involved in developing care plans. People's records contained minimal information and failed to show involvement from them and their relatives, where appropriate. Therefore, we could not be assured these had been developed in line with people’s individual preferences and supported the delivery of person-centred care.

Person-centred information about people was not robustly documented and there was limited guidance in place that demonstrated how and where people would like to receive their personal care. Some staff we spoke with told us they had not seen a care plan, or where they had the plans didn’t contain enough information. Life histories were not included and there was minimal information about people’s abilities. There was no evidence available to show that care records were routinely reviewed when people’s needs had changed. These concerns formed part of the breach of legal requirements relating to governance, which is reported on further in the Well-Led section of this report.

People we spoke to told us they were supported by staff who knew them well. Both people and their relatives confirmed that they received the correct care.

There were some shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

People and relatives told us they were happy with the care and support that was provided and that it was in line with what they expected. The majority of care visits were carried out at agreed times and were delivered by a consistent staff team that people were familiar with. Staff told us they sometimes felt rushed but said the registered manager was flexible in allowing calls to run over to ensure all agreed care was provided.

However, some staff we spoke to told us that they did not always have access to sufficiently detailed or up‑to‑date information about people’s care needs. They explained that this sometimes made it difficult to share relevant information with other health care professionals in a timely way.

The provider did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The provider failed to meet the requirements of the Accessible Information Standard. This standard is a legal requirement for social care providers to ensure information and communication is provided in a way that meets people’s needs and can be understood. Other than a brief statement of intention in the ‘Equalities and Health Inequalities’ policy, there were no processes in place to make sure people received information in the way they preferred. People’s communication needs had not been robustly assessed and there was no information in the care plan about their preferred methods and format of communication. We could not be assured that people were receiving information in the most appropriate format for them.

Despite our concerns, people we spoke with did not specifically highlight communication as an issue.

The provider did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not always involve people in decisions about their care or tell them what had changed as a result.

People we spoke with told us they had not a formal review of their care. No formal meetings had been facilitated or questionnaires distributed to give people who use the service and their families an opportunity to have their voice heard. There was a basic complaints process in place, however the registered manager told us that no complaints had been received so we were unable to review the effectiveness of this process.

Despite the lack of formal feedback processes people, relatives and staff told us the registered manager was approachable, and they felt confident that any issues or concerns raised would be dealt with promptly and appropriately.

The provider did not always make sure that people could access the care, support and treatment they needed when they needed it.

While people told us that the care they received was in line with what had been expected, the provider did not have effective oversight in place to ensure people’s care was delivered as agreed.

Care plans did not contain robust information for staff about how to recognise when people were unwell and when to refer people to health professionals. People did not have specific care plans in place to provide guidance to staff on how to safely support them with some diagnosed conditions such as diabetes. Whilst we found no impact on people during our inspection, there was a risk staff would not always recognise signs of deterioration and when to refer people to other health professionals. We did see evidence confirming people received regular routing interventions from district nursing teams and other health professionals.

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

Care plans contained no information about people’s equality and diversity needs. No information was recorded about people’s cultural or religious beliefs. Additionally, there was no documentation regarding other protected characteristics, such as disability, sexual orientation, or gender identity, and no indication of the support provided to prevent discrimination or uphold human rights. This placed people at risk that their needs may not be fully understood, or their rights might not be upheld. Despite these omissions, we did not identify any direct impact during our inspection.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

One person’s care record indicated a wish to remain at home in their final days. This person had a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form in place.