AJ Case Management

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 outstanding.

This meant people’s outcomes were consistently better than expected compared to similar services. People’s feedback described it as exceptional and distinctive.
 

This service scored 92 (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 always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff used a wide range of assessment tools to identify the level of support people needed for areas of their life such as their mobility, personal care, and their nutritional needs. People’s physical, communication, social, cultural and religious needs along with any protected characteristics as defined by the Equality Act 2010 were all considered. Once assessments were completed, bespoke care plans were created and agreed with the person and their family. Staff then had clear, detailed and individualised guidance for each person they supported.

Staff worked collaboratively with external healthcare professionals to maximise the effectiveness of care and support. For example, one person who experienced hypersensitivity was assessed by a sensory integration practitioner. This is a health professional, often an occupational therapist, who specialises in the assessment and treatment of people with sensory difficulties to improve daily skills and their quality of life by addressing their unique sensory processing needs. Following this assessment, tailored strategies were implemented, including the use of a weighted blanket and the development of a step by step care plan. This enabled staff to provide an aspect of personal care in a way which minimised distress and met the person’s sensory needs, resulting in their improved comfort and wellbeing.

Assessments were exceptionally thorough and outcomes focused, which ensured people’s needs were fully understood and met. People’s goals and expected outcomes were clearly documented so staff understood what each person wanted to achieve and how the support they gave would promote their independence, wellbeing, and choice. People’s assessments and care plans consistently identified their individual needs, desired outcomes, potential risks and hazards and the specific support interventions required for each person.

People also had detailed routines which guided staff on how best to support them throughout the day. These routines were developed following a comprehensive initial assessment by the case manager and were developed with the person and their family to ensure they reflected what the person wanted and needed. This person‑centred and collaborative approach ensured people’s care plans were effective and supported care which achieved positive outcomes for people.

Each person’s care plan identified the monitoring and recording tools staff were required to complete, such as food and fluid charts or observational records. These were reviewed and audited by managers, which helped to support effective oversight and continuity of care.
 

The provider always planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation. They worked to develop evidence-based good practice and standards.

People received care and support which was in line with national good practice standards. Staff training was up to date and relevant to their roles which helped staff deliver care and support which was up to date with current required standards and national legislation. Each section of people’s care plans directed staff to the associated company policies, procedures and guidelines which supported each activity. For example, where 1 person was supported with their mobility, the care plan directed staff to follow the provider’s mobility and falls management policies. This ensured staff were aware of, and adhered to, the most current practice and expectations for safe and effective practice.

People’s eating and drinking needs were met and staff followed plans set by Speech Language Therapists (SaLT). This provided staff with the skills to support people with safe swallowing where they were identified at risk of choking from fluids or food. Some people had assistive technology to support them with eating and drinking. Staff received training to ensure they could operate the technology safely and effectively.

People’s care plans identified any specific training staff must complete before delivering care and support to them. This training was individual to each person and their specific health needs such as epilepsy, acquired brain injury or cerebral palsy. One person’s nutrition and hydration care plan directed staff to food hygiene, health and safety and first aid training and company policies. Each section of people’s care plans also indicated how staff competence for that specific activity would be assessed. For this person, staff competency was achieved through assessment and training by the SaLT, Occupational Therapist and Dietician, along with spot checks by a team leader who would also review records staff had completed.
 

The provider worked well across teams and services to support people. They made sure people only needed to provide their information once by sharing their assessment of needs when people moved between different services.

Staff worked closely with external professionals to make sure people received joined up care. One health professional told us the case managers ensured there was collaboration between all external professionals, staff and the person’s family to ensure a continuity of their care. Another told us, “Each person has a good network of professionals around them. It feels like a team.”
Because staff knew the person they supported well, they would advocate on their behalf. If people who received 24hour care required hospital admission, their staff team accompanied them to ensure continuity of their care and effective communication with the clinical teams.

Each person had a summary of their care needs and an “All about me” section within their care plan. This provided other professionals with a clear and accessible overview of the individual, including any allergies, the support they required, tasks they could complete independently, and their communication needs.

Some people had pre‑prepared hospital bags, which staff ensured went to hospital with them. These bags contained essential communication tools and important information to help hospital staff understand the person’s needs and preferences.

The provider always supported people to manage their health and wellbeing to fully maximisetheir independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

People were supported to take part in a wide range of meaningful activities which promoted both their physical and mental wellbeing. One person told us they particularly valued the social activities they attended with staff support. These included a volunteer‑led community group where they took part in cooking sessions, bowling, theatre visits, shooting activities and cricket.

The provider had a Supporting Wellbeing Policy which guided staff to understand the importance of emotional, physical and social wellbeing and how this directly impacted the experiences of people using the service. The policy emphasised the value of building positive relationships, promoting a sense of belonging, and supporting people to develop self-worth. Relatives all told us about the positive impact on their family member due to the support staff gave them. One person called their family members’ case manager “intuitive” and said, “They took the lead. They got right on board in getting the right people [professionals] in place. Staff got involved in keeping the communication technology going and [Person’s name] is now so much happier as a result.”

Staff were encouraged to create opportunities for people to share achievements and positive experiences, contributing to improved confidence and overall wellbeing. Staff shared people’s “good news stories”, such as one person successfully completing the Great North Run with the support of their staff team.
 

The provider monitored all people’s care and treatment to continuously improve it. Theyensured that outcomes were positive and consistent, and that they fully met both clinicalexpectations and the expectations of people themselves.

People and their relatives consistently told us staff made a significant and positive difference to their lives, resulting in greatly improved outcomes and wellbeing. One relative described their family member as “living their best life,” and explained how staff supported them to pursue a wide range of meaningful and enriching activities which reflected their interests and aspirations.

People and their family were involved in reviewing and agreeing their care and identifying the goals they wished to achieve. Specialist support was utilised to help ensure care plans were of good quality and followed best practice guidance. One relative told us, “Staff will arrange support such as physiotherapy or occupational therapy. They [staff] follow the plans they put in place to make sure everything is right. I’m involved; they go through everything with me.”

Staff demonstrated a strong commitment to enabling people to live their lives as they wanted to and achieve their goals. Staff we spoke with told us they ensured one person arrived at activities on time, was fully prepared, and had the right equipment, including specialist support such as an off‑road wheelchair. This proactive and enabling approach supported the person to complete the Great North Run and raise money for charity. This demonstrated how staff consistently focused on outcomes which mattered to people, supporting them not only to meet their goals, but to live fulfilled, active, and meaningful lives.

Staff worked as part of a multi-disciplinary team where clinical guidance was obtained as needed and utilised to ensure positive outcomes for people. Staff told us they worked to improve the lives of the person they supported. One staff member told us they could call on occupational therapy, physiotherapy, neuro therapy and speech and language therapy to ask for their input when new equipment and technology was needed. Another staff member told us a person was trialling a new specialised bike and wheelchair to replace their existing ones. This would improve their quality of life.

The provider had effective processes in place to ensure any updates in people’s care needs were shared with staff. Regular governance, audits and observation of staff practice took place to ensure care remained effective and at the expected standard.
 

The provider told people about their rights around consent and respected these whendelivering person-centred care and treatment.

People’s care plans clearly detailed how staff should support people to give consent to their care. Care planning consistently reflected the principles of the Mental Capacity Act 2005 (MCA), with consideration given to each person’s ability to make informed decisions and the support they required to do so.

People and their relatives were supported to state their preferences for care and support. One person told us staff always asked them for their permission before anything was done which involved them.

Where people could not consent, decisions were made in their best interests in line with the principles of the MCA. People’s care plans provided clear guidance for staff, outlining how to assist them with everyday decision‑making, including choices about food, clothing and social activities. One staff member said, “MCA is built into [Person’s name] care plan.” Another staff member explained how they supported the person they supported to make choices in a way which was accessible and meaningful for them. Staff offered a limited number of options to the person, such as choosing between two pairs of trainers, two items of clothing, or two different drinks. This approach ensured the person was not overwhelmed and was able to make informed decisions in line with their assessed capacity.