Crescent Office

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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

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

The service was in breach of legal regulation in relation to consent.

This service scored 46 (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.

We received mixed feedback from people and relatives about their involvement with assessments and care planning. Some told us they were not involved while others said they had. For example,1 person said, “I had an interview, and a care plan was made out.” Care plans did not always reflect people's needs and preferences. Not all people had up-to-date assessments in relation to their mobility, eating and skin needs. This placed people at risk of receiving inappropriate care and support.

Care was not always delivered in line with legislation and current evidence-based good practice and standards.

Care and support did not always reflect current evidence-based guidance, standards and practice. For example, the provider was not always using a skin assessment tool when people were at risk of skin breakdown. When risks to people were identified, action was not always taken to reduce them. For example, people were not always supported to reposition or use prescribed creams to support skin integrity.

The International Dysphagia Diet Standardisation Initiative (IDDSI) is a set of descriptors describing textured modified food and drink for people with eating and drinking problems. Care plans about this were conflicting, and staff demonstrated they did not always understand current guidance in relation to people with swallowing problems. This put people at risk of harm.

Despite this, people mostly told us their care was planned with them. For example, 1 person said, “I was involved with setting up my care plan at the pre assessment and its followed correctly”. The provider conducted periodic reviews with people, and records demonstrated if people requested changes with the care provided, the provider would aim to support these.

A registered manager told us they attended forums with partner agencies to support them to keep up with best practice and ensure they were following latest guidance. However, this did not cover all the best practice needed to deliver high-quality care.

The provider did not always work well across teams and services to support people.

Care plans did not provide information about how staff were expected to work with external professionals to provide joined-up care for people. For example, 1 person had very sore areas on their skin. The person was supported by staff at Crescent Office, the community nursing team, GPs and the pharmacy. The care plan did not specify how they should work together to support this person or who held what responsibility. The lack of coordinated care increased the risk of the skin condition not improving in a timely manner. Staff described the person’s skin issue as ‘ongoing’. On other occasions, when staff informed partner agencies of other issues, it was more successful, and people got the right support.

Care staff told us communication between the office staff and themselves was good and they valued the support from them. Most staff told us they worked well as a team.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

Care plans did not provide detail about the health conditions people lived with. For example, diabetes and multiple sclerosis. Staff did not always understand how to support people with their health needs effectively. For example, they did not always support people to maintain healthy skin in line with their needs or to eat the correct consistency of food.

However, the provider had an effective system where staff could handover concerns about people’s health. Care staff told us they or office staff would call other services such as a GP, community nurses or paramedics if they felt people needed support from these services. One person told us, “I was sleeping a lot and the carer that comes in noticed. She did say to Crescent [office staff] and they contacted the doctor.” Staff also passed on health concerns to family members when this was appropriate. Relatives confirmed this. For example, 1 relative told us, “Once she [Person] was very confused and they [staff] were very alert to notifying us about it in case she had a urine infection, and we contacted the doctor.”

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.

Processes needed improvements to monitor people's care and treatment effectively. For example, where a person was at risk of pressure ulcers and required repositioning, records did not demonstrate this was carried out in line with their assessed need. Another person experienced frequent distress, but there were no monitoring records to identify triggers, themes, trends or factors that could reduce their distress.

People’s goals and expected outcomes were not recorded in their care plans. This meant staff did not always know what people were working towards or how to help them achieve their goals. However, some staff had got to know people’s needs well and knew how to support them to achieve good outcomes. Reviews took place with people and their relatives told us they were overall happy with how the staff supported them to have good outcomes.

The provider was not working within the principles of the Mental Capacity Act 2005 (MCA). The registered managers and staff did not have a clear understanding of the MCA and when it should be applied. The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves.

Records demonstrated people had consented to their general care at the start of their contract. However, no consent, mental capacity assessment or best interest decision records about specific decisions or where there were restrictions on people had been undertaken. For example, if they had bed rails which restricted their freedom of movement, or their medicines were locked away.

A registered manager told us they had not undertaken any mental capacity assessments for any person, despite daily records showing there may be reason to query some people’s capacity to make some decisions. This meant the principles of the MCA were not adhered to.

Staff demonstrated a limited understanding of the MCA. However, records showed staff offered people choices in their day-to-day care, such as what they wanted to eat or wear. People and their relatives confirmed this.

People can only be deprived of their liberty when this is in their best interests and legally authorised under the MCA. When people receive care and treatment in their own homes an application must be made to the Court of Protection for them to authorise people to be deprived of their liberty. Daily records showed 1 person was stopped from leaving their house due to concerns about their safety. The provider had not worked with the local authority to ensure legal processes were followed in line with the MCA. This meant they may have been unlawfully detained. We raised this with the registered managers and the local authority, and this was being reviewed at the time of our inspection.