Ryedale Homecare

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.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People received an initial assessment of need when they joined the service. However, these assessments were not consistently developed into full working care plans or risk assessments within reasonable timescales, even where individuals had been receiving regulated activity for several weeks. This included people with dementia, continence needs, mobility needs and those requiring personal care, meaning their needs were not fully assessed or recorded in sufficient detail to guide safe and effective care.

Key person‑centred information, such as communication needs, preferences and guidance for safe support, was not always captured within these initial assessments, limiting staff’s ability to deliver effective and individualised care.

During the assessment, the provider updated and completed care plans only after receiving CQC feedback. This demonstrated a reactive approach, rather than a routine, systematic process for assessing and reviewing people’s needs.

The provider did not always ensure that care and treatment was delivered in line with evidence‑based guidance. While initial assessments were completed for 2 people, these were not consistently developed into full care plans or risk assessments within expected timescales, which limited staff’s ability to draw on structured, evidence‑based information to guide care delivery.

During the assessment, several care plans were only updated or completed following CQC feedback, demonstrating a reactive rather than systematic approach to embedding evidence‑based practice.

Where detailed plans were in place, particularly for people with a learning disability, care planning included risk assessments for example, choking, hydration and seizure‑related risks, communication guidance, and behavioural support strategies that reflected recognised good practice. However, care plans were not completed consistently within the service, and several people did not have completed care plans for staff to follow.

Pain assessment tools such as the ‘Abbey Pain Scale’ were used for people who could not verbally communicate discomfort, aligning with best practice for people with cognitive or communication impairments. Staff had completed Autism Awareness Level 2 and Disability Awareness training, which supported understanding of communication, sensory regulation and pain interpretation for autistic people and people with a learning disability.

Staff, teams and external partners did not always work together in a coordinated way to support people’s care. The provider relied heavily on informal staff communication rather than structured systems to identify or share changes in people’s needs, and the registered manager acknowledged the lack of auditing and oversight that would normally support effective teamwork and information flow.

Following CQC feedback, the provider updated several care plans and risk assessments to include detailed information from social workers, health professionals and learning disability teams, demonstrating that collaborative working could be effective when initiated, but was not routine practice.

The manager reported collaboration with social workers when supporting people with a learning disability or autism. The service used hospital passports and liaised with learning disability teams when needed. However, these examples did not reflect the level of day‑to‑day coordination, which remained inconsistent.

Inconsistent information‑sharing processes and the absence of structured assessment and review systems meant staff, teams and partners did not always work together effectively.

The provider did not always support people to manage their health and wellbeing in a proactive or consistent way. Some people had only an initial assessment of need, with no timely development of care plans or risk assessments to guide staff to manage health‑related needs such as dementia, mobility, continence, stoma care and long‑term conditions. This limited the provider’s ability to support people to maintain or improve their health.

Where detailed care plans were in place, information about physical health conditions, communication needs and risk management was clearly documented. The provider used tools such as the Abbey Pain Scale to support recognition of pain and discomfort in people who could not verbally communicate, aligning with good practice. However, this was not consistently applied across the service.

The provider did not always ensure that assessments, care plans and monitoring systems supported people to live healthier lives or reduce future care needs.

The provider did not always monitor people’s care and treatment in a way that supported continuous improvement or ensured positive and consistent outcomes. Reviews of care documentation showed that daily care logs were not routinely reviewed. This meant changes in people’s needs were not routinely identified or acted upon.

Our assessment identified the lack of an effective system to complete and review care plans and risk assessments. This demonstrated a reactive approach to improving outcomes instead of a proactive system for identifying and addressing emerging risks and health needs.

Although some individuals with a learning disability had detailed care plans aligned with recognised best practice, these examples were not consistent across the service. There was no evidence of a systematic approach to measuring or improving outcomes across the wider service.

The provider did not consistently monitor people’s care or use information to drive improvement, resulting in variable outcomes.

People were asked for their consent to care and treatment, and records showed that initial assessments included sections relating to capacity, communication and decision‑making needs. Care plans for people with a learning disability included communication guidance to support staff to explain choices and check people’s understanding in line with person‑centred practice.

Where people lacked capacity to consent to aspects of their care, records showed that appropriate representatives signed consent decisions. This information was recorded within the care plan and helped to reflect the level of support required for day‑to‑day choices.

Staff had received training in autism and learning disability. This improved their ability to recognise communication cues, assess comfort or distress, and support people to express their views wherever possible. This helped staff to apply consent principles appropriately for people who communicate non‑verbally or through behaviour.

Staff demonstrated an understanding of consent and the Mental Capacity Act, and some records reflected good practice.