My Carer

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question Outstanding. At this assessment the rating has changed to Good.

This meant people’s needs were met through good organisation and delivery.

This service scored 68 (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 made sure people were at the centre of their care and treatment choices and worked in partnership with people to respond to changes in their needs.

Staff had a good understanding of people's individual needs and were able to describe how they supported people in ways that promoted comfort, independence and wellbeing. Staff also understood when it was appropriate to involve other professionals to help ensure people received the right support at the right time.

However, people's care plans were not always sufficiently detailed or person-centred. Important information about people's preferences, routines, aspirations and what mattered most to them was not consistently recorded. As a result, care records did not always reflect the personalised knowledge staff held about the people they supported or demonstrate how care was tailored to meet people's individual wishes and goals.

There was some evidence people and their relatives were involved in developing and reviewing care plans. However, this involvement was not always clearly documented.

The registered manager explained that many people using the service and staff had developed longstanding relationships, resulting in staff having a detailed understanding of people as individuals and often viewing them as extended family. However, they recognised this knowledge was not always reflected within care records and agreed to take action to ensure care plans were fully completed and accurately reflected the person-centred support people received.

Staff had access to care records and demonstrated a good understanding of the people they supported. When speaking with staff, they described people's needs, preferences and routines in detail and spoke respectfully about them. One member of staff told us, “I think it is clear to see that we have great working relationships with our clients. Most of them are always surprised that we fit into their lives, not alter their lives for us. I feel incredibly privileged that our clients let us into their lives and homes, and I believe this is easy for them because of how we are as a team. Our clients are always telling us how much they think of us and are happy to have us.”

Despite the limitations in recording, people and professionals consistently described care as personalised and responsive to individual needs, demonstrating that staff knew people well and adapted support to what mattered most to them.

There were some shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

People told us staff understood their needs and provided care in line with their preferences. Staff knew people well and were able to explain how they adapted support to meet individual needs and circumstances. People were supported to access healthcare services when required, and the provider worked with a range of health and social care professionals to help promote people's wellbeing.

However, systems to ensure care was planned, coordinated and reviewed were not always effective. Care records did not consistently reflect people's current needs, preferences or risks, and were not always updated following healthcare appointments, changes in circumstances or receipt of professional advice. As a result, records did not always provide staff with accurate and up-to-date information about how to support people.

Staff told us they communicated changes in people's needs verbally and demonstrated a good understanding of the people they supported. However, reliance on staff knowledge reduced assurance that care could be delivered consistently, particularly by staff who were less familiar with the person or covering shifts.

The provider worked with external professionals and supported people during periods of transition, including following hospital discharge. Whilst professional advice was sought appropriately, this information was not always incorporated into care plans or reflected within daily records in a timely manner. This meant there was a risk that changes to people's support needs were not consistently communicated across the staff team.

We found weaknesses in care planning and record keeping which limited the provider's ability to demonstrate that care was always coordinated and responsive to changing needs. The provider could not consistently evidence how professional recommendations, including those received following hospital discharge, had been translated into care plans and practice. This reduced assurance that people would always receive personalised, joined-up care and support that reflected their current needs.

Although people's outcomes were not adversely affected at the time of our assessment, the provider's systems for maintaining accurate care records and ensuring continuity of care required improvement. This was because records did not always support the consistent delivery of person-centred care or demonstrate effective coordination between the service and other professionals involved in people's care.

The provider did not always demonstrate that people were supplied with appropriate, accurate and up-to-date information in formats tailored to their individual needs.

Policies and procedures were in place to support people with different communication needs. However, there was limited evidence to demonstrate how the provider ensured information was presented in ways people could understand and access. Care records did not consistently show how people's communication needs had been assessed, reviewed or incorporated into day-to-day care delivery.

Despite this, staff demonstrated a good understanding of people's communication needs and were able to describe the approaches they used to support effective communication and engagement with people. Staff told us they adapted their communication to meet individual needs and took time to ensure people understood information and were able to express their views and preferences.

However, the lack of clearly recorded communication needs and preferred communication methods reduced assurance that this information would be consistently available to all staff, particularly new or unfamiliar staff. As a result, the provider could not always demonstrate that people had access to accurate, personalised and accessible information to support their involvement in decisions about their care and treatment.

The provider did not always ensure people could share feedback and express their views in ways that met their individual needs. Opportunities to gather and act on feedback were not always fully effective.

Procedures were in place to gather people's feedback. However, surveys were not always provided in accessible formats. For example, one person's care plan stated that receiving letters triggered their anxiety and that written information was difficult for them to process. Despite this being known, they received the annual service user questionnaire in the same format as everyone else.

However, some people told us they were regularly asked for their views about the service. One person said, “They review my care more than once a year. Maybe 2-3 times a year and they call me. I get a survey by post, or the carer will bring in a sealed envelope. I put my name on it, but it can be anonymous.”

In addition, there was limited evidence demonstrating how feedback was analysed, used to drive continuous improvement, or communicated back to people. This meant opportunities were missed to develop a robust understanding of people's experiences and to evidence actions taken in response to feedback from people, staff, leaders and partners.

We shared this feedback with the provider during the assessment, and they took action to begin improving their approach.

The provider made sure people could access the care, support and treatment they needed when they needed it.

The service worked in partnership with key organisations, including local authorities and healthcare professionals, to help ensure people received timely access to care and support.

People told us the service responded appropriately when their needs changed. One person said, "We started with half an hour, after a couple of months I was reassessed and now I have an extra 15 minutes." This demonstrated the service reviewed people's needs and adjusted support arrangements to help ensure they received appropriate care.

People were involved in decisions about their care and future support needs. One person told us, "They are open to hear my suggestions," and explained they had ongoing discussions about how their care would increase as their health condition progressed.

Professionals consistently described the service as flexible and responsive. One professional said, "They were flexible in how they adapted to changing needs and were able to maintain a good level of continuity." Another professional told us, "They demonstrate flexibility in meeting service users' changing needs and maintain continuity of care where possible."

Professionals also described the service as proactive in ensuring people could access the support they needed. One professional commented staff "worked well alongside other services, shared information appropriately, and were proactive in contributing to safe and coordinated care."

Feedback from people and professionals indicated the provider adapted support as needs changed and worked with partner organisations to help ensure people received timely and appropriate care.

Staff and leaders understood which people were most likely to experience inequality in their experiences or outcomes and used this information to provide highly personalised care, support and treatment.

Equality and diversity policies were in place, and staff had received equality and diversity training to ensure people's care, treatment and support promoted equality and protected their rights.

The provider demonstrated a strong understanding of people who were more likely to experience inequality, social isolation or poorer outcomes and showed that meeting these needs was integral to the service's purpose. They took a proactive and personalised approach to supporting people at increased risk of loneliness and exclusion.

For example, the provider recognised that some people were at heightened risk of isolation during festive periods because of reduced mobility, financial constraints, long-term health conditions and limited family support. One person told us, "It's amazing the amount of things they [staff] do for us, but they make sure we are involved in anything that's going on like Easter and Christmas. I get birthday cards, Christmas cards, gifts, Christmas meals, I'm never made to feel isolated."

Professionals consistently described staff as caring, compassionate and person-centred. One professional said staff were "friendly, considerate, compassionate and professional in their approach to their role." Another professional told us, "They build a good rapport with the clients who look forward to their visits."

Professionals also told us staff understood people's individual needs and wellbeing. One professional stated, "Staff had a strong understanding of the person's needs and delivered care in a genuinely person-centred way, taking into account both their mental health and overall wellbeing." Another said, "Staff show a good understanding of the people they support and take a personalised approach to care."

Feedback demonstrated staff consistently went beyond people's expected care needs to promote wellbeing and reduce social isolation. One professional described how staff and managers delivered Christmas presents to people using the service and said, "It was lovely to see the smile on the face of a [person] who lives alone and is bed bound."

Professionals also highlighted positive outcomes achieved through the support provided. One professional commented, "The person's quality of life noticeably improved as a result of the care and support they provided."
 

People were supported to plan for important life changes, so they had enough time to make informed decisions about their future, including at the end of their life.

The provider supported people to consider their future care needs, including aspects of end-of-life planning, although this was not always fully detailed for every individual. Care records showed people's current needs and preferences were reviewed regularly, and there was evidence of sensitive and person-centred conversations taking place where appropriate.

Staff demonstrated a good understanding of the importance of supporting people to express their wishes and preferences for future care. Staff told us they felt comfortable having these conversations and would seek additional guidance when needed. Where people had shared their preferences, these were documented and respected to help ensure care remained aligned with their wishes.

A relative of a person receiving end of life care told us, “Staff are genuinely interested in my [relative's] good outcomes.” Relatives consistently told us they were satisfied with the care their family members received.

People were given opportunities to discuss how they wanted to be supported if their health needs changed in the future.

The provider recognised the importance of continuing to develop this area of practice and had begun taking steps to strengthen how future planning discussions were documented, reviewed and shared. This helped support people's choice and control over their care, including decisions about their future and end of life care.