Aim24 Care Wokingham

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 newly registered- service. This key question has been rated requires improvement.

This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

This service scored 58 (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’s systems for assessing and reviewing people’s health, care, wellbeing and communication needs were not always effective, and people’s experiences of involvement in this process varied. We received mixed feedback about whether people felt included in their assessments. Some people told us they were unsure if they had been involved, and others said they had not been given a copy of their care plan, meaning they were not always fully informed about their support. Care plans we reviewed generally contained enough information to guide staff to deliver care safely and consistently. Staff told us they read care plans before providing support and felt they contained sufficient detail. They also said they would report any changes in needs to the office. Despite this, people’s understanding of the assessment and care planning process differed, and not everyone felt involved or aware of how their care was reviewed.

People told us they received regular calls from the office to check whether their needs had changed. Where people did not have copies of their care plans, the provider supplied these following the inspection.

The provider assessed people’s needs using recognised tools and aimed to deliver care in line with legislation and evidence based best practice. However, gaps in documentation meant it was not always clear assessed risks were being followed through in day to day care. For example, required skin integrity checks and the volume emptied from catheters were not consistently recorded, despite these being identified in the care plan as requiring monitoring. These omissions created a risk people’s assessed needs would not be consistently met in practice.

The small size of the service meant people mainly received support from a consistent staff team, which helped maintain continuity of care. Staff told us they had access to the information they needed to provide support and said communication within the team was effective. They reported they could contact the office if they needed guidance or updates about a person’s needs.

One care plan we reviewed did not include the complete specialist information, from the Speech and Language Therapy (SALT)professionals. This meant staff did not always have the full detail needed to support coordinated care where other professionals were involved. These gaps were addressed during the inspection. People told us the office made regular contact to check whether their needs had changed, and staff said they passed on any updates promptly. This helped ensure relevant information could be shared with other services when required.

The provider supported people to manage their health and wellbeing in ways that promoted independence, choice, and control. Staff encouraged people to live healthier lives and, where possible, reduce their future need for care and support.

People’s healthcare needs were included in their care plans, and information about diagnosed conditions was recorded. However, in some cases, care plans did not describe how a person’s health condition affected them on a day to day basis. This limited staff’s ability to deliver fully informed and personalised care. Care plans directed staff to monitor specific aspects of people’s health, such as checking pressure areas. However, this monitoring was not always documented consistently, and gaps were not always identified through audits. As a result, the purpose and value of the monitoring were reduced.

The provider could not always demonstrate effective monitoring of care and treatment to support continuous improvement. Audits of care plans and daily notes were not consistently robust and did not identify several concerns found during the inspection. Audits took place regularly, however they did not always lead to actions or improvements being implemented. However, people and relatives told us they were contacted regularly about changes in care needs and were generally happy with the service, stating staff monitored needs well. People told us staff knew them well and would recognise changes in their relative’s condition. One person said, “They will notice if there are any symptoms”.

People were supported to have control over their day to day choices. Staff were patient and gave people the time they needed to make their own decisions. People and their families were appropriately involved in key decisions about their care.

The Mental Capacity Act 2005 (MCA) provides the legal framework for making decisions on behalf of people who may lack the capacity to make specific decisions for themselves. Staff had completed MCA training, and organisational policies were aligned with MCA principles.

Mental capacity assessments and best interest decision records were in place for the majority of relevant decisions. However, some records lacked sufficient detail, and in certain circumstances, such as the use of bed rails documentation was not present.