One to One Community Care

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• 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 requires improvement. At this assessment the rating has remained 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.

The provider did not always make sure people’s care and treatment were effective. Assessments for people’s care needs were completed prior to support starting but were not comprehensive and the information collected did not always transfer through to care plans. Care records lacked clarity for staff to be able to support people effectively. Care plans were not person centred and often lacked detail of health conditions, how a person wanted to be supported as well as information around capacity and communication. For example, one person had recently had several falls but there was no information in their care plan referring to a falls history or measures to reduce future risk. We also found some conflicting information in peoples’ care records. For example, one care plan had information about a person’s visual impairment, however their risk assessment was ticked ‘no’ for this person having a visual impairment. There was a lack of effective oversight from leaders in relation to assessing on-going needs and care planning. This meant people were at risk of not receiving safe care that met their needs.

The provider planned and delivered people’s care and treatment with them, including what was important and mattered to them. We saw evidence of involvement from other health professionals. However, recording of health professionals’ involvement and ongoing health conditions for people was inconsistent resulting in care plans not being person centred or detailed. Staff recorded information about care and support they provided but there was no evidence of how this information was reviewed and analysed to identify common themes so plans for additional tailored support could be put in place if required.

The provider did not always work well across teams and services to support people. We saw evidence of professional involvement across care records, but information provided by professionals which did not transfer into the people’s care plans. For example, one person was noted by health professionals to have an allergy. This information was not collated, recorded or shared with staff. Staff were positive about their contact with managers. They told us they felt supported, and managers were responsive. A staff member commented on the support they received, “I have support from my manager and my colleagues.”

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. We could not be assured people were receiving consistent support to improve their health and well-being as records of reviews were not always completed. Care records did not always provide information for staff on people’s health history or current conditions. Guidance wasn’t always available to guide staff for what to look for and what action to take should someone’s health decline. However, we saw no evidence that this had impacted negatively on the care and support people received. People and their relatives told us they were supported to access health services when they needed to. A relative told us, “Any concerns and they are very efficient in contacting me or the emergency services if necessary.”

The provider did not always routinely review, monitor and record people’s care and treatment to continuously improve it. Care plans and medicines records were not being robustly audited to ensure risks were assessed and mitigated. We could not be assured people’s needs were always accurately monitored, or concerns were escalated to professionals in a timely manner. Lack of effective systems to provide service level oversight could potentially result in themes and trends not being identified and missed opportunities to improve service delivery.

The provider did not always assess and record people’s rights around consent.People’s capacity to make decisions were not always assessed and where people lacked capacity to make decisions, the provider failed to record the decision-making process. People’s care plans did not always contain sufficient information about the type of decisions they were able to make and how best to support them to make these decisions including any support a person may need with communication.However, staff received training in the Mental Capacity Act and understood the importance of ensuring that people fully understood what they were consenting to and the importance of obtaining consent before care was delivered. One staff member told us, “I ensure that the people within my care are included constantly, ensuring they are part of every step and communicating effectively.” Another staff member told us what they would do if someone refused support, “I would try to find out why they didn’t want the care as there may be something upsetting them or another reason. I would then report it to family and my manager. I would also log it.”