Woodhall Care Services Ltd

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.

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 the legal regulation in relation to consent to care and treatment at the service.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always make sure people’s care and treatment was effective because they did not record people’s care, wellbeing and communication needs in sufficient detail. Care plans lacked person centred information including people’s likes, dislikes, choices and preferences. Some people’s care records said they ‘had confusion’ but there was no detail of how this may present or affect them and the support they may require. Care plans had contradictory information recorded around one person’s continence needs which meant staff could not be sure what support this person needed. Where one person, cared for in bed, needed repositioning, care plans lacked detail as to how staff should support them, and how to record this to demonstrate appropriate care.

The registered manager had identified this and created an action plan to make improvements. Staff had completed training in record keeping and the format of the care plans was under review.

The service did not always plan and deliver people’s care and treatment with them, including what was important and what mattered to them. We looked at one person’s care plan who was described by the registered manager as receiving end of life care. Records showed the person had declined to discuss their wishes and preferences around end of life care. There was no evidence of any further recorded discussions with the person or with people who knew the person well. The management team said they were making improvements so people’s end of life wishes could be established at assessment and included within care plans to ensure more person centred care and outcomes.

The service 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. The service worked quickly to complete initial assessments and provide prompt care to people referred and needing care services.

The service supported people and worked with relatives to ensure people’s health and wellbeing was managed to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

The service 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. Care visits did not always reflect the allocated time visits should have been made to support people’s needs. Call logs showed some significant shortfalls in the allocated times for visits and the actual time spent on visits by staff. Records showed staff spent variable amounts of time during each visit, sometimes less that the allocated time for each person, and sometimes more. It was not clear what the rationale for this was.

The service did not have consistent information recorded in care plans about people’s abilities and their rights around consent when delivering care and treatment. The registered manager and nominated individual told us everyone who used the service had capacity, although information recorded in care plans did not support this and contained inconsistent information. Staff we spoke with, although had received training, had a lack of knowledge around consent and capacity. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. We require the provider to review and update consent and capacity decisions to ensure they are current and in line with the MCA. During our ongoing assessment of the service, we were provided with an updated copy of a care plan. Capacity, lack of and best interest decisions were clearly recorded on the updated copy received.