Personalized Care Services

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

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

There were robust systems and processes in place to support the assessment of people using service. Assessments were completed by the service with input from relevant agencies such as the local authority or hospitals. People’s assessment needs were well detailed in care plans. People told us their needs were well assessed. One relative told us, “A risk assessment was done when [my relative] came home from hospital.”

The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

Leaders completed regular reviews with people or their relatives. However, care plans lacked important detailed information to support evidence-based care. For example, people’s care plans detailed specific health or cultural information which was not supported by relevant guidance, evidence or legislation. At times, care plans contained contradictory information pertaining to people’s health needs, and whose responsibility it was to support these needs. The service made immediate improvements to their care plans and documentation following the assessment feedback.

The service 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.

Professionals told us the service worked well with other services to support people’s needs. One professional told us, “The team have made great effort to provide a good service of care for my client.” Staff told us there was a positive working environment with colleagues in the service to support people’s needs. One staff member told us, “There is good colleague support here [at the service].”

The service 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 were supported to live healthier lives by supporting with shopping and attending local activities, including social visits. Professionals told us the service was committed to improving the health of the people they supported. One professional told us, “[The service] has supported both clients and staff to engage in meaningful health and wellbeing activities.”

People told us they maximised their independence by completing any personal care tasks they were able to, and this was well supported by staff.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or they met both clinical expectations and the expectations of people themselves.

People’s care was regularly reviewed and leaders completed handover meetings where any areas of concern were discussed. However, it was not always clear what actions had been taken to address areas of concern. For example, when people displayed distressed behaviours. There was a lack of information to show how leaders in the service had responded to these concerns, or any action plan suggested.

We received mixed feedback from people as to whether their care was monitored to improve outcomes. One relative told us, “We are in contact a lot [with the service], they [the service] will ring me with any concerns.” However, another relative told us, “[My relative] has a specialised wheelchair but they have not been supported to get out of bed.” It was unclear what actions had been taken by the service to escalate concerns. The service advised us how they planned to make improvements in this area.

The service did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

There was appropriate consent documentation in place which had been signed by people or their relative. However, documentation was not embedded with relevant legislation, for example, the MCA (2005). People told us they were asked about consent during their care. One person told us, “They [staff] always tell me what they are going to do.” The service has told us what improvements they planned to make.