Home Instead Senior Care

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• 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

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. People’s needs were assessed in a person‑centred and decision‑specific way, with detailed assessments that were regularly reviewed. Care plans reflected people’s physical health, emotional wellbeing and communication needs, and were responsive when people’s needs changed. Families, advocates and unpaid carers were appropriately involved, and their roles were clearly recognised and recorded.

The service demonstrated how comprehensive assessments identified immediate risks and longer-term recovery goals. An example of this was when a personalised reablement plan was developed to promote independence, rebuild confidence and improve daily living skills for people who were struggling with mobility issues. Assessments were regularly reviewed, and care was adapted as people’s needs changed.As a result, both of these people regained confidence and independence, enabling care to be reduced from 24-hour live-in support to a lower level of domiciliary care while remaining in their own home. Family wellbeing also improved as dependence on support reduced. This demonstrated how effective assessment and care planning led to positive and sustainable outcomes. People’s care needs were stored electronically, on a system known as ‘Birdie’. This provided staff with access to people’s care records via handheld devices, which they could update, documenting any changes in people’s health and wellbeing.

People and their relatives confirmed they were involved in any changes into their needs, with relatives being very complimentary about having access to care records, which enabled them to monitor the service being provided. A relative told us, “The care plan is all on the ‘Birdie App’ which reflects [persons] needs and can be updated.”Another person told us “I have a care plan. They come out every so often, going through sections and recording any changes. [Staff member] came out 2 to 3 months ago as I was struggling with my mobility, they advised what would help and referred me to health professional.”

Staff demonstrated strong knowledge of the people they supported and used assessments proactively to identify changes in need and escalate concerns promptly. Records showed people were supported to work towards personal goals and that care was adapted as circumstances changed. Staff told us, “We know our clients very well and we know if something is wrong, we then report and tell the manager and call the doctor.”

Professionals provided positive feedback about the service’s thorough approach to assessment and responsiveness to changes in need.

The service's strengths-based approach ensured assessments considered people's history, preferences, and abilities, enabling care to remain personalised, proactive and responsive to changing needs.

The provider made sure people’s care and treatment was effective by planning and delivering care in line with legislation and evidence‑based guidance. Care plans were informed by people’s assessed needs and risks and reflected relevant guidance where appropriate. Mental Capacity Act documentation demonstrated appropriate application of the Act, with decision‑specific assessments and clearly recorded outcomes.

Reablement-driven care planning and multidisciplinary working resulted in improved wellbeing, greater engagement, and increased independence for people, while reducing the need for intensive support. This demonstrated how the service delivered care in line with recognised rehabilitation, reablement and prevention principles to achieve positive outcomes for people.

The service used evidence-based interventions to support recovery, maximise independence and help people achieve goals that were important to them. As a result, people experienced improved outcomes, reduced reliance on care and support, and were able to remain living safely in their own homes and communities. This showed that care was consistently focused on promoting progression and independence rather than maintaining dependency.

Staff identified changes in people’s health and wellbeing and escalated concerns promptly, including contacting GPs and other professionals. Records showed care delivery was adjusted in response to changes in need. Staff told us they monitored people closely and shared concerns with managers so timely action could be taken.

People and relatives reported confidence in staff knowledge and training and felt reassured that health concerns were identified and addressed early. One person told us, “They understand my Parkinsons. Yes, I have confidence in them.”

Theprovideralways worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once.The provider demonstrated effective partnership working to deliver safe, person-centred and coordinated care. Staff worked collaboratively with healthcare professionals, including GPs, community services, therapists and hospital discharge teams, to ensure people's needs were assessed, monitored and responded to in a timely way. Referrals were made promptly when people’s needs changed, and relevant information was shared to support continuity of care.

Evidence showed multidisciplinary working supported safe transitions, continuity of care and positive outcomes. For example, coordinated discharge planning enabled people to return home safely following hospital admission and regain independence, resulting in reduced care needs. Partnership working with families and external professionals also helped ensure care remained responsive and aligned to people's changing needs.

The provider actively engaged with wider health and social care partners, including dementia support services, integrated care initiatives and provider networks, demonstrating a commitment to continuous improvement, innovation and sharing best practice.

This approach helped people access the right support at the right time, reduced the risk of deterioration and promoted independence, wellbeing and positive outcomes.

Staff described clear systems, supportive management and effective communication within the team, which helped them deliver consistent care. Staff spoke positively about teamwork and felt well supported by managers, which contributed to joined‑up care for people. Professionals told us the service was empathetic and professional and that communication supported positive working relationships.

One professional told us, “As a service, the staff are trained in dementia care, and I have a lot of trust in the staff to deliver person-centred and effective care interventions for the clients. For example, a husband was struggling to get his wife to attend to her personal care needs, which was ongoing for months. Home Instead were employed to help this lady. They initially trialled once a week to get the lady used to them. This was successful. They gradually and slowly introduced care and now the client accepts care from the carers.”

The provider supported people to live healthier lives by identifying health concerns early and promoting access to healthcare and community support. Staff recognised risks to people’s health and wellbeing and took preventative action, including close monitoring and escalation of concerns to managers and healthcare professionals.

People were supported to attend health appointments and to access activities and routines that mattered to them. Care planning promoted independence and reflected people’s interests and preferences. Staff told us they reported concerns promptly and involved doctors when needed. People and relatives described proactive support that helped them maintain their wellbeing and independence.

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

The service used governance systems to drive improvement. The provider monitored and improved outcomes for people through effective oversight, auditing and learning from feedback. Records showed people’s needs were monitored over time and support was adjusted to achieve positive outcomes.

Information was used proactively to drive improvements in the quality of care, with learning translated into staff development, service improvements, and better outcomes for people. This demonstrated a positive learning culture, where continuous improvement was embedded in day-to-day practice rather than driven solely by governance processes.

This approach demonstrated organisational self-awareness, responsiveness, and a commitment to ongoing improvement, helping to ensure people received safer, more effective, and continually improving care.

The provider demonstrated a person-centred approach, ensuring individuals remained central to decisions about their care. People and their relatives told us that staff understood their needs, reviewed them regularly, and responded promptly when any changes occurred. This helped ensure people continued to receive care that aligned with their preferences and supported their wellbeing.

Feedback from people and their families was positive. Several described meaningful improvements in wellbeing linked to the support provided and spoke warmly about the caring attitudes of staff. Relatives told us regular staff provided consistent and reliable care. One described staff as, “Wonderful and attentive, they help me achieve a positive outcome. I am not supposed to get out of bed without support. I was going mad. They supported me to get out for a few hours, and I do some painting with their support. It helps me with my mental health.” Another relative told us, “The support they give her has led to positive outcomes. She can live in her home.”

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment. Consent and capacity were clearly recorded in care plans. Mental Capacity Act assessments were decision‑specific and appropriately documented, and best‑interest decisions were recorded where people lacked capacity, reflecting their known wishes and preferences.

The service promoted and supported decision-making and ensured people remained at the centre of decisions about their care wherever possible. Care plans were personalised and reflected people's preferences, routines, life histories and goals. This enabled staff to provide care that was tailored to individual needs and what mattered most to people. Family members were involved, where appropriate, to support decision-making and help maintain continuity of care. Staff had undertaken training and understood the areas of Mental Capacity Act 2005 (MCA) that were applicable and ensured that they asked for consent and offered choices to people. Staff told us they involved people and families in decisions wherever possible. Records supported this and showed consistent application of the Mental Capacity Act across the service.