Archived: 23 Perryn Road

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• 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 changed to requires improvement.This meant people’s needs were not always met.

The service was in breach of legal regulation in relation to ensuring care was person‑centred.

This service scored 54 (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 were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

Care delivered did not always reflect people’s routines or preferences, and meaningful activities had reduced, with people often disengaged. Relatives reported, “Residents would just be sitting there with the TV on,” and “They [people] used to go out but now they are always in the home.” Relatives told us clothing and bedding frequently went missing, affecting dignity and personalisation, with 1 family member saying, “We used to buy clothes and duvets, but they would go missing.” Another relative reported, “(Name of family member’s) clothes are always too tight, we buy new clothes, but (name of family member) is not often seen in them.” We shared all feedback given with the management team.

The management team had reviewed the rotas to align staffing with activity plans and community access. Updated rotas, including named responsibility for activities and 1-1 support were shared with us to evidence the changes made. These issues were also identified within the provider’s and the local authority’s joint improvement plan, to ensure people’s social and community needs could continue to be met.

There were some shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

Staff described peoples’ individualised needs and how they would support them. However, this was not consistently translated into practice, and staff familiarity with people’s needs fluctuated, particularly during periods of staffing shortages. Communication systems such as handovers and expectations to read the files were in place, but this was not always followed. Relatives reported limited involvement in reviews and poor communication about significant events.

Relatives spoke of marked inconsistency in how well staff understood their family members. A relative commented, “I don’t know of current staff who really understands [name of family member], they look ill and unhealthy.” Another relative reflected, “Before it was more in order, but lately I cannot understand what’s happening.”

People also experienced a decline in meaningful routines and stimulation. One relative commented, “There is no stimulation” and others described activities which previously supported continuity, such as annual barbeques and outings, had stopped. Another relative noted that while there were examples of good practice earlier in the placement, “Some staff were consistent and there were times when you saw a new face,” which contributed to fluctuating oversight and engagement.

Although there were examples of engagement with healthcare professionals, relatives also raised concerns when important professional advice was not followed, highlighting further gaps in coordinated, consistent care.

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

We found people were supported in ways that recognised and responded to their individual communication needs. Support plans provided clear guidance for staff, including the importance of avoiding overwhelming questions, allowing adequate processing time, and enabling the person to initiate interactions at their own pace.

Accessible communication tools were actively used, and families highlighted how these supported more effective engagement for example, staff had pictures to communicate with people. People also benefited from accessible documents such as communication passports, hospital passports, and hospital letters, which were available for staff to reference when providing care.

The provider did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support.

Some relatives told us that involvement had previously been positive, with regular updates, collaborative discussions and action taken on feedback particularly around community access. However, these practices were no longer consistent. Many relatives described a noticeable decline in communication, explaining that updates and photos had stopped, and that experiences varied significantly. While some continued to feel included, others felt excluded, uninformed and no longer welcomed by the service.

Staff demonstrated efforts to support choice and dignity by asking about people’s preferences and paying attention to non‑verbal cues. One person had an advocate who supported their involvement, and there was no evidence that anyone requiring advocacy had been overlooked. Despite these examples of good practice, the overall picture was inconsistent. Managerial instability contributed to gaps in communication and engagement, and repeated failures to involve people and families undermined more positive elements of practice.

The provider had a complaints policy, and relatives were aware of how to raise concerns. One relative had made a complaint that was still under investigation at the time of the assessment, and another relative told us they felt comfortable raising safety concerns. However, these individual examples of engagement did not mitigate the broader pattern of inconsistent communication.

The provider did not always make sure that people could access the care, support and treatment they needed when they needed it.

Poor planning of the environment meant the service could not always meet people’s changing mobility needs. When a person began to need wheelchair‑accessible facilities, these were not available, which limited how staff could support them with personal care and meant the placement could no longer meet their needs.

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes.

Some relatives told us visiting had become more restricted, as the previous open‑door approach was no longer in place and families were expected to contact the service before visiting. We shared this feedback with the management team, who said they had not been aware of these changes and found it difficult to follow up due to the former registered manager’s departure.

Practices like this could create an inequitable experience for relatives and reduce opportunities for meaningful connection with family members.

People were not always 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.

Care plans documented what peoples’ long term goals were but failed to document how they were going to be met and if they were regularly reviewed to consider any further changes in peoples’ circumstances.

Relatives told us they were not always given the opportunity to discuss their family members’ end‑of‑life preferences, and staff confirmed this did not always happen. End of life care was not included in mandatory training, meaning staff were not fully equipped to provide appropriate support when people approached the final stages of life. At the time of our visits, no one was receiving end of life care. The provider informed us end of life care was delivered in line with specific service requirements and was therefore categorised as service specific training rather than mandatory training within the organisation.