Archived: 23 Perryn Road

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.

The service was in breach of legal regulation in relation to person-centred care and need for consent.

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 ensure people’s care and treatment were effective because their health, wellbeing and communication needs were not consistently reviewed or discussed with them. Care plans showed people’s needs had been assessed, but information recorded was not always accurate or complete. This meant we could not be confident people received care that consistently met their individual needs or promoted positive outcomes.

There was no evidence relatives were routinely involved in care planning or reviews. A relative told us they had, “Not been involved in any reviews” and only found out about incidents when they contacted the service themselves. Another relative explained they had, “Never been to an annual review meeting”, and were not consulted after falls or changes in their family member’s health needs. A third relative said they were previously invited to reviews, but this had stopped, and they were now only asked for their “opinions,” rather than being included in decisions about care.

This lack of involvement meant important information known to relatives was not consistently incorporated into care planning. As a result, people’s care plans did not always fully reflect their needs, preferences or risks, limiting the provider’s ability to ensure care was accurately assessed and personalised.

Peoples’ nutritional needs and health needs were not always met.

People’s weights were recorded; however, only data for January 2026 was provided, so we could not determine whether monitoring occurred at appropriate intervals or whether trends were reviewed.

There was no evidence staff used recognised tools such as Malnutrition Universal Screening Tool (MUST) to assess risks of malnutrition or dehydration, meaning early signs of deteriorating health may not have been identified. Support plans for people who were overweight did not include evidence-based guidance or dietary instructions linked to specific health conditions, leaving staff without clear direction.

Mealtime observations showed food offered did not always support balanced nutrition. Food and fluid charts recorded multiple daily entries, but lacked daily targets, totals and consistent completion, particularly at weekends and evening, so we could not confirm whether peoples’ hydration needs were reliably met.

Staff and professionals did not always have the reliable details they needed to coordinate care effectively. Information needed to support people’s care was recorded in various documents, including the communication book, care records, health action plans and hospital appointment summaries. However, these records were sometimes inaccurate or not used effectively. This affected coordination of care and the ability to provide safe, well-informed support.

For example, a person’s hospital passport included key information for hospital staff, it stated they did not have heart problems, which contradicted their Health Action Plan (HAP) where a heart condition was recorded. It also stated the person had asthma, but there was no reference to this in their support plan, risk assessments or HAP.

A Risk Enablement Panel (REP) meeting held on 9 April 2025 considered an increase in another person’s distressed behaviours. This was attended by internal management staff only and did not involve family members or relevant health and social care professionals who could contribute to multidisciplinary decision making. The panel identified staff were not accurately reporting incidents and agreed the manager would address this. However, we found evidence staff continued not to follow incident reporting procedures, and there were no records to show other agreed actions had been completed. As a result, information sharing across the wider team was inconsistent, and opportunities to coordinate safe and effective support were sometimes missed.

Staff did not always have the information they needed to support people effectively. For example, 1 person’s care record stated they needed to be referred to an occupational therapist, but there was no record to show this referral had been made. Other health needs were documented without clear instructions for staff, and where guidance was available, records did not show it was consistently followed.

People had activity plans to support physical and emotional wellbeing. Staff facilitated activities during our first site visit; however, on our second site visit, due to unexpected staff sickness planned activities did not happen. People who required 1-1 support were left without staff engagement for periods of time, reducing opportunities for meaningful activity.

The provider had already identified some of the concerns within their service improvement plan. The management team were receptive to our feedback and updated the plan to show when specific actions had been completed or were in progress.

Health action plans (HAP) were in place; however, they did not always contain the information staff needed to monitor people’s health conditions effectively. For example, a person’s HAP stated they had a specific health condition and advised staff to report concerns to their GP, but it did not describe the symptoms staff should look out for, or the actions required to prevent deterioration. This meant staff did not have a clear or consistent approach to supporting the person’s health needs.

Despite these gaps, people were supported to attend healthcare appointments, including those who found this difficult due to distressed behaviours. We saw examples where staff used structured and reassuring approaches to help people overcome anxiety about medical environments. A person, who previously avoided appointments, was supported through a desensitisation programme at a local hospital and successfully received their COVID‑19 vaccinations. This contributed to improving their long-term health outcomes.

Hospital passports were available and helped hospital and medical staff understand how people communicated, how they preferred to take their medicines, how they mobilised and the support they required with personal care.

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

Where people were unable to make specific decisions relating to personal care, medicines and finance, having a lock on the service’s front door, mental capacity assessments (MCA) were not always completed to ensure their human rights were protected.

Care records did not always document people’s view or consent, specifically where people were not able to sign to agree to various aspects of care and support, no best interest decision meetings were held.

The provider had already identified these concerns, and work was in progress at the time of our inspection to ensure these were addressed.