Office 510 Kingsfield Close, NN5 7QS

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,treatmentand support achieved good outcomes and promoteda good qualityof life, based on best available evidence.At our last assessment we rated this key questiongood. At thisassessmentthe rating hasremainedgood.

Good:This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

This service scored 62 (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’s care and treatment were effective because they did not always check and discuss people’s health, care,wellbeing and communication needs with them. The assessment process was focused on the assessment completed prior to people’s discharge from hospital. After this, the service relied on staff feeding back information gleaned whilst supporting people to populate and update care plans and risk assessments. Care plans were inconsistent. Some plans were detailed and contained person-centred information and details on people’s preferences around how their care was delivered, whereas others were brief and did not contain sufficient information. People told us they felt involved in care planning and believed they had access to their care plans. However, the Registered Manager told us the care plans were written without people’s involvement, and they did not have access to these.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.The Registered Manager told us they did not complete their own assessments using nationally recognised tools,such as the Malnutrition Universal Screening Tool (MUST) or the Waterlow tool for assessing skin integrity. These were provided by the hospital, prior to people’s discharge, but they weren’t used to inform care planning.The Registered Manager told us they access training sessions for providers through the Local Authorityto help them stay up to date on best practice.

The provider worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.Staff told us that updates were shared with them via handovers at the start of shifts, team meetings and the electronic care system used by the service. The management team worked with the hospital and local authority to ensure peoples transition home from hospital and then on to long-term care was seamless. Staff worked effectively to share information about people’s routines and preferences with the management team to ensure care plans were tailored to people’s preferences.

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.The service had different levels of involvement in managing the health of people they were supporting. Some people using the service had assistance from relatives in liaising with their GP and other health professionals. Staff told usthey “spot deterioration through changes in behaviour, appearance or vital signs. Then monitor, document and report to the manager or healthcare professional.”

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. Whilst desired outcomes and goals were recorded in people’s care plans, there were no steps in place to ensure these were goals that people genuinely desired for themselves. Nor had care been systematically reviewed to measure progress against these goals. People told us that staff saw them as individuals. One person told us, “We’re very good friends.” Care packages were monitoredby staff sharing informationon their day-to-day observations of care with the management team and care plans subsequently being updated.

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment. People told us that staff always talked to them about what they were going to do. Although the electronic system the service used did not effectively record people’s consent to their care plans, we saw evidence of signed consent forms that were kept in people’s homes. Staff told us “I gain consent by explaining care or supportin a way the person understands, checking they agree, and respecting their decision.” Staff recognised people’s right to refuse assistance and supported them to make informed choices about their care.