Wendleberrie House

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 remained Good.

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

This service scored 67 (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 ensure people's assessed needs were fully reflected in complete and up-to-date care planning documentation. Although people's needs were assessed before admission and reviewed regularly, care plans were not always completed in line with the provider's own processes.

The provider completed pre-admission assessments to help ensure they could meet people's needs before they moved into the service. Assessments considered people's physical and mental health, personal care needs and preferences to support effective care planning.A relative told us, “Assessment was done with person and family”.People's care plans and assessments were reviewed regularly and updated when their needs changed.

However, we found that care plans were not always completed in line with the provider's admissions process. For one person, some care plans remained incomplete after they had moved into the service. Although staff knew the person's needs well, incomplete care plans increased the risk that important information was not consistently recorded to guide staff. The provider acknowledged this and confirmed the outstanding care plans would be completed.

The provider planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

The provider used recognised assessment tools to assess and monitor people's needs and risks, including the Malnutrition Universal Screening Tool (MUST) and the Waterlow assessment tool.Assessment outcomes were used to inform care and reduce risks. For example, where a person experienced repeated falls, additional equipment was introduced to help keep them safe.Where concerns were identified about people's nutrition or weight, appropriate referrals were made to healthcare professionals, including dietitians, to ensure people received specialist advice and support.

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 were organised well to meet people's needs. Each shift was led by a senior member of staff, and management support was available outside normal working hours when needed.Staff shared important information during handovers to make sure they were aware of any changes in people's care and support needs.

Staff worked well with health and social care professionals to help meet people's needs. Staff told us they felt supported and could ask senior staff or healthcare professionals for advice when needed.A healthcare professional told us staff knew people well, worked well together and followed professional advice.A relative told us, "They always inform me if there's been any incident or if (relative) got an appointment."

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.

People's health, nutrition and hydration needs were assessed and monitored. Staff supported people with their day-to-day health needs and took appropriate action when concerns were identified.A relative told us, “The staff at the home know if (relative) is not right and they ensure they have drinks of orange juice and hot chocolate”. Another relative told us, "Yes they (staff) make sure (relative) drinks (fluids) and eats readily".We observed a relaxed and positive mealtime experience. We found people had a choice of meal options and that snacks were also available.People were encouraged to be as independent as possible and were offered a choice of meals and alternatives if they did not want the main meal.People were encouraged and supported to take part in activities that promoted their physical, mental and emotional wellbeing.

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

The service used an electronic care record system to record and monitor people's care. Care plans and risk assessments were reviewed regularly and updated when people's needs changed.People's health and wellbeing were monitored, and staff worked with health and social care professionals when additional support was needed.People at risk of dehydration had fluid intake targets in place, and records showed these were monitored. People at risk of constipation had care plans, bowel monitoring charts and clear guidance for staff to follow.We reviewed records for people with urinary catheters. Records showed catheter care was monitored, including urine output, catheter bag changes and any concerns.

The provider did not always assess and record people's mental capacity in line with the Mental Capacity Act. Some decision-specific assessments were incomplete or did not clearly show how decisions had been reached.

Where people lacked capacity to make specific decisions, the provider had completed Mental Capacity Act (MCA) assessments and best interest decisions. We reviewed a sample of records and found assessments had been completed for a range of decisions, including consent to care, medicines, where people lived and the use of bed rails.

However, we found that MCA assessments were not always completed in line with the principles of the Mental Capacity Act. Assessments did not always clearly record how staff had reached the conclusion that a person lacked capacity, including the information provided, the person's responses, and how these demonstrated they were unable to understand, retain, use or weigh information, or communicate a decision.We also found that decision-specific MCA assessments had not always been completed for all relevant decisions about people's care and support. For example, assessments were missing for decisions about modified diets, information sharing and photography.During our visit, we observed staff asking people for their consent before providing care and support.