Blue Ribbon Community Care (Tyne and Wear)

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 good. At this assessment the rating has remained good. This meant people’s needs were met through good organisation and delivery.

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 were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

The management team told us there was a close working relationship with people and their family members to support good communication and person-centred care delivery. People’s care needs were closely monitored and reviewed every 3 months, and the management team took prompt action whenever concerns were identified to ensure issues were addressed in a timely manner.

Care plans were person-centred and detailed what was important to each person, their emotional wellbeing, and how they wished staff to support them. Staff were introduced before care started, worked in small named teams where possible, and had access to care plans before visits.

The service used “This is me” to understand people’s background, interests and preferences. Staff also received extra information or specialist training, such as PEG feeding or SALT support, when needed. This helped staff build relationships, notice changes quickly and provide consistent, personalised care.

The provider understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

The management team involved families to share information and gather feedback. Challenges in care were quickly identified and communicated to both internal staff and external professionals for support. As a result, care was regularly reviewed and adjusted to meet assessed needs.

 People were valued for their abilities and potential. They received support from a consistent, well-trained staff familiar with their individual needs.

The provider stayed up to date by taking part in local care networks, webinars and trusted health and social care groups. This helped leaders keep informed about changes, learn from others and share current information with people, staff and families.

The provider supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The accessible communication needs of people were also fully considered and acted upon through the providers full and comprehensive assessments. This ensured people had an information plan, and the service could access the necessary support equipment. The evidence showed the provider was meeting the Accessible Information Standard (AIS) which states providers must assess and record people’s communication needs and provide information in accessible formats.

The provider made sure information was shared in ways that suited each person and their family. Staff had communication training, and care plans explained how best to communicate with people. The service used whiteboards, phone calls, Teams meetings, emails, letters and rotas to keep people informed. It also used technology, such as digital daily records, so people and relatives could access information more quickly.

The provider made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff involved people in decisions about their care and told them what had changed as a result.

The provider and staff demonstrated a strong commitment to continuous improvement by employing a variety of methods to gather feedback and suggestions. They regularly engaged with individuals and their families. Surveys were given to people using the service and their families to get their opinions. Many examples showed that the service listened to what people said and made changes based on their suggestions to improve the care and support provided.

The provider listened to people and involved them in their care through regular 3-monthly reviews and ongoing discussions about any changes or concerns. People, relatives and staff knew how to raise complaints, and the service kept clear records of concerns, actions taken and outcomes. People were kept updated throughout, which showed the provider took feedback seriously and responded in an open and timely way.

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

The provider had systems and processes that monitored people’s care and support needs, including health conditions. People’s care plans and records confirmed how people’s care and support was provided, monitored and reviewed.

Staff were available whenever people needed assistance including in emergencies, such as overnight, when an on-call system was in place. People praised how responsive and communicative the service was and told us they could always speak promptly with a staff member when they needed to. One person who used the service said, “The staff I can’t fault, they’re available 24/7, they are always at the end of the phone.”

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

People received individualised care meaning people’s experiences were consistently positive including those most likely to experience inequality. The provider strongly advocated on behalf of the people they supported, examples of this included supporting people to express their views during meetings, helping people access services and speaking with other healthcare professionals if they had concerns. Staff also delivered care that went above and beyond to ensure people’s outcomes were consistently positive, adapting care as needed to meet people’s needs.

People discussed barriers to treatment, and care plans were created for support. Where people needed adjustments, these were noted in hospital passports and brought to appointments and healthcare settings.
 

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

No one currently using the service was receiving end-of-life care. People’s future and end of life wishes had been considered if people and their families wished to. The service actively supported people towards greater independence and to have less care interventions where possible.

Staff had regular training, and the service kept clear records of people’s wishes, including EHCPs, DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) decisions and LPAs. These were monitored and reviewed so people’s choices were known and respected.