AJ Case Management

On this page

• 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.

At our last assessment we rated this key question good. At this assessment the rating has changed to outstanding.

This meant services were tailored to meet the needs of individuals and delivered to ensure flexibility, choice and continuity of care

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This service scored 93 (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 was exceptional at making sure people were at the centre of their care andtreatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Staff told us they had built good relationships with the people they supported, and they ensured each person’s care was tailored to their individual needs. This was echoed by relatives we spoke with. One case manager told us, “I make sure the person is surrounded by an amazing multi-disciplinary team and promote a working together approach.” People’s care plans clearly reflected their personal preferences and the aspects of their life which were most important to them. They also included any characteristics protected under the Equality Act, such as their disability, spiritual, cultural or other relevant needs and how staff should support them. One staff member told us, “I deliver person centred care by following [Person’s name] care plan, preferences, and by adapting my support to their individual needs rather than using a one size fits all approach. I promote choice, independence, and inclusion, while also balancing this with safety and risk management.”

People and their relatives told us they were included in the planning, reviewing and any decision making in relation to their care. They told us all staff, including external health professionals all worked well together. One relative told us they felt “fully” involved in their family member’s care and in making shared decisions. Staff had explained everything to them and if there were any changes, the updated care plan was agreed with them.

One person had a highly detailed step-by-step guide in place which clearly set out how staff should support them in the exact way they wanted. This guide had been developed after the case manager had completed an initial assessment and then was written with the person and their family to ensure it fully reflected their preferences and needs. The guide included photographs to demonstrate the correct support techniques, including details such as how the person liked to be positioned at night time and the position of their sheet and quilt. This exceptional level of personalisation ensured consistency, comfort, and dignity, and demonstrated the provider’s commitment to person centred care.
 

The provider had an exceptional understanding of the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

People benefited from their own staff teams who knew the person well and understood their care needs. People’s care was delivered in a truly co-ordinated way with partnership working being at the forefront of people’s care. They had access to and excellent working relationships with external professionals including occupational therapists, dieticians, therapists and physiotherapists which were arranged by staff. The provider further strengthened practice by arranging bespoke training which equipped staff with a clear understanding of litigation processes, the impact this had on people and specialist conditions such as vestibular issues associated with brain injuries. This all contributed to responsive, well-informed care which promoted positive outcomes, continuity, and improved quality of life.

People’s staff teams met regularly, and records demonstrated a co-ordinated approach to their care with a strong emphasis on continuity and achieving the best outcomes for people. Staff worked closely with people’s external health professionals to manage their changing health needs and share information appropriately. Professionals confirmed contact and engagement with the service was good. This helped to promote their physical wellbeing and created a co-ordinated approach to their care. One case manager told us they advocated for people during multi-disciplinary meetings and with external agencies.

The provider supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Each person had a personalised communication care plan which identified their preferred communication methods, barriers to communication, and how staff should support them to understand information and express their views and wishes. One person living with agnosia had a detailed care plan which clearly explained their condition and how it affected their communication. Agnosia refers to an impairment of the ability to process and interpret sensory information. The plan provided clear guidance for staff to watch, listen, acknowledge, and respect responses while supporting them to understand information.

The Accessible Information Standard was embedded into people’s care plans, so staff could support them to communicate effectively and receive information in a way which met their individual needs. This standard sets out how providers should ensure disabled people and people with impairments or sensory loss can access and understand information. One staff member explained when they were with the person they supported in the community, they were there to support them and assist them if there was any difficulty in them understanding anything.

The provider’s Equality, Diversity and Human Rights Policy reflected their commitment to ensure all people could access information in a way which met their individual communication needs in line with the Accessible Information Standards. These standards described how providers review people’s communication needs and make reasonable adjustments to ensure they can access the information they need.
 

The provider made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff involved people in decisions about their care and told them what had changed as a result.

One relative told us they would feel comfortable to talk about anything which was of concern or wasn’t safe. They felt they would be listened to if they made a complaint and it would be addressed quickly. Another relative told us, “[Case manager’s name] listens to me. I have no concerns, but I know they’ll take on board anything I say.”

The provider had not received any complaints. One staff member showed us they had a complaints tracker, but this was blank. The registered manager explained they took a proactive approach to resolving any issues and managers addressed these promptly to prevent them escalating into formal complaints. People and their relatives had a contact list, including out of hours contacts so they had access to the service at any time.

People and their relatives were asked to complete an annual survey, which included questions aligned closely to the CQC domains. Feedback was positive and it enabled the provider to seek meaningful feedback on people’s experiences of the service. People and their relatives were also actively involved in their day to day care with staff. They were given regular opportunities to share their views, raise concerns, and contribute to decisions about their support, ensuring their voices were listened to and valued.
 

The provider was exceptional at ensuring people could access the care, support and treatment they needed when they needed it.

People’s staff teams worked together to ensure they were able to access services. They ensured reasonable adjustments were made so people could access and use services equally. These included adjustments relating to physical access, communication methods, and the use of technology, which enabled people to engage with services in ways which met their individual needs. One person had been supported to have access to private services. The provider had worked in consultation with the person’s legal team, family, support team and the person so they could ensure safe practice with this aspect of their life. It also ensured the person could access the service in the way which worked for them and removed barriers to inequality. One staff member told us they saw their role as being an advocate for the person they supported to ensure they were not discriminated against.

People received their care and support in line with best practice and legal requirements. Staff used an accessible version of the Mental Capacity Act with people and their families to help explain their rights and who can be involved in making decisions about their care, such as independent mental capacity advocates (IMCA’s) or court appointed deputies. These advocates of the person ensured they had equal access to services and were not discriminated against due to their disabilities.

Where staff required additional bespoke training, particularly any input from therapists, this was appropriately coordinated and delivered. One external professional told us, “I am contacted to offer advice and give training to staff which is tailored specifically for the person.” This ensured staff had the relevant specialist knowledge and skills to support people to safely access care and treatment in line with their assessed needs.
 

Staff and leaders were innovative in how they listened to information about people who are most likely to experience inequality in experience or outcomes. Staff and leaders actively used this information to provide exceptionally tailored care, support and treatment in response to this.

People received equity in terms of their experiences and individual outcomes. Regardless of people’s disability or health need staff were committed to providing exceptional and individual care and support. They worked to remove barriers, protect their human rights and source equipment and resources to improve people’s lives. One case manager told us, “I also work closely with families, therapists, and external agencies to remove barriers, promote independence, and create opportunities for the person to achieve positive outcomes and long‑term stability. My role is to ensure the whole system around the individual is safe, consistent and working towards their best possible quality of life.”

People were supported to maintain their independence and achieve meaningful goals. One staff member told us the staff team would alter the hours they worked to fit around the needs of the person they supported. Staff ensured any activity the person wished to do could be accomplished. This included working later so the person could attend the many shows and “gigs” they liked to attend or changing shifts to be able to support the person on holiday. They said, “I also think staff work well together as a team to deliver consistent care and support each other where necessary.” This reflected a culture of person-centred and equitable care and ensured their right to good care was upheld.

Staff were alert to potential discrimination which could disadvantage the person they supported. One staff member told us, “[Person’s name] could possibly face discrimination due to their disability by assumptions being made and/or reduced opportunities to access community services.I work to challenge this by offering choice to engage in the activities they enjoy, in a way that is accessible to them. Also, by supporting them to fully express their wishes.”

The providers Equality, Diversity and Human Rights policy focused on delivering care and support in a person-centred way which respected people’s choices, preferences, dignity and privacy regardless of background, identity, belief, ability or circumstance.

People were given exceptional support to plan for important life changes, so they could make informed decisions about their future, including at the end of their life.

People were supported to plan for their future through person centred planning, which included the development of individual goals and making plans for their future care needs, housing and educational needs, holidays and trips. They worked with the person, their representatives and other professionals to support people to plan for their future and achieve their long term goals. This helped to promote choice, aspiration, and meaningful experiences, supporting people to make the most of opportunities available to them.

The service did not support anyone who was deemed at the end of their lives. However, some people had plans in place which detailed arrangements for potential health emergencies they may have, such as cardiac arrest or sepsis.