TogetherCare

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 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 75 (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’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

People and relatives mostly agreed assessments were carried out before care started and reviewed regularly, with people’s consent and family involvement where appropriate. One relative said, “The care plan reflects her current needs,” another relative said, “There are certain tasks that they [staff] know they’ve got to do for mum.” Some relatives, however, could not tell us if the person had a care plan in place. We looked at a number of care plans which we selected, and every person we reviewed had a care plan in place.

Information from assessments was used to develop detailed care plans covering people’s holistic needs, including physical and mental health, communication preferences, the home environment and personal goals. 

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.

Care plans reflected current professional guidance where required, including advice from specialist services such as speech and language therapy (SALT) for dysphagia and clinical guidance for long term conditions or complex needs. Staff understood how to follow these plans and adapt their practice when people’s needs changed. Professionals were given access to online care system which allowed them to have oversight of people’s needs and conditions in real time.

People and relatives told us staff knew their family members well. Managers were also familiar with people’s needs and provided oversight to ensure information remained current.

The registered manager told us they subscribed to all relevant practice updates, including CQC newsletters, local authority provider networks, work force development and skills for care. This ensures their knowledge is also relevant and up to date and can make changes to care delivery if necessary. A professional told us, “The agency demonstrates a strong commitment to innovation, with a clear focus on continuously improving the quality-of-service delivery and achieving the best possible outcomes for the people it supports”.

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.

Internal communication systems supported coordinated working. Staff received operational updates through team message applications, electronic alerts and meetings, with important information shared promptly. Managers had oversight of the staff who had and had not accessed and read the necessary information which enabled quick action.

Staff collaborated effectively with each other, families and external professionals where appropriate to support people’s needs. Referrals and escalations were made in a timely way and were clearly documented.

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.

Care plans showed staff encouraged people to make healthier life style choices, this included meal planning and shopping. People were encouraged to participate in meaningful activities and make choices that promoted healthier lifestyles.

Professionals told us the provider was proactive and supported people to continue living at home, maximising their independence and choice.

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

Staff were proactive in helping people achieve positive outcomes.

Regular audits of care records, including daily care notes and medication administration records (MARs), were carried out to ensure care was delivered in line with care plans and people's wellbeing was closely monitored. These audits enabled the registered manager and care management team to identify trends, monitor outcomes, and recognise when care arrangements needed to be reviewed or adapted to meet changing needs.

An electronic live-visit monitoring system was in place, with a dedicated senior manager providing real-time oversight to ensure visits were conducted at the appropriate times and, where possible, for the planned duration.

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment.

The provider promoted people’s rights under the Mental Capacity Act 2005 (MCA). Records we reviewed showed capacity was considered on a decision specific basis, and best interest processes were used when required. People were involved in decisions about their care, with families or others consulted where appropriate.

Staff told us they understood the importance of asking for consent from a person and including people in decision making about their own health and support. They completed training in relation to mental capacity and understood how to support people to make choices about their care.