Achieve Together Limited

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.

We observed staff delivering person-centred support that reflected people’s individual needs and preferences. People appeared comfortable and engaged with staff, interacting positively through conversation and sharing information about their day and planned activities. Staff adapted their approach in response to people’s communication styles and preferences.

People told us they felt understood by staff. One person told us, “They understand me and know what I need.” A relative also told us, “Staff know [person] probably better than I do. They know their favourite music, what they like to eat and when they need peace and quiet.” This demonstrated that staff had developed detailed knowledge of people as individuals.

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 service used a key worker system which worked well. People told us they knew their key worker well and had been asked about their preferred choice of staff both for allocation of key workers and for daily activities. This supported consistency and ensured relationships were developed in line with people’s preferences.

Staff received training specific to people’s health conditions, and induction records evidenced support to understand the needs of people using the service. This helped ensure staff were equipped to deliver consistent and appropriate care.

Rotas evidenced continuity of care, and the service had not used agency staff for over six months. This supported stable staffing and enabled staff to develop consistent relationships with people, promoting continuity and stability in care delivery.

The provider supported people to access their preferred activities and source alternative activities when funding had been changed.

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

Pre-assessments included clear information about people’s communication needs, and staff supported people in line with these assessed needs. Staff demonstrated a good understanding of how each person communicated, and this was clearly recorded in care documentation, supporting consistent communication approaches. For example, 1 non-verbal person used their own gestures to communicate with staff. Makaton was not used for this person at the time of inspection as alternative communication methods were more effective and preferred.

Pictorial aids and communication cards were available, however, where these were not effective, staff continued to explore alternative approaches in a person-centred way. For 1 person, staff were developing a pictorial guide using the person’s own photographs due to disengagement with other communication tools. For another person, assistive technology (iPad) was used effectively to support both communication and engagement in activities.

Key information such as consent forms, support plans, hospital passports and risk assessments were available in easy read formats. Policies and procedures, including those relating to the Accessible Information Standard and the General Data Protection Regulation (GDPR), were current and aligned with best practice guidance.

Relatives also reported being kept well informed. One relative told us, “Whenever I ask about something, they’re always able to answer and if they can’t they tell me they’ll get her keyworker to phone me back and they do. They keep me informed.” This demonstrated effective communication and responsiveness to family needs.

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 kept them informed about changes made as a result of their views.

The service held monthly meetings with people to gather feedback, discuss concerns and plan care in line with their needs. Records confirmed these meetings took place and showed people were actively involved in discussions about their support. The provider also used additional feedback methods, including a barcode system and the “Your Home Your Say” survey, which collected views from people, staff, visitors, healthcare professionals and family members. Feedback was mainly positive, indicating people felt able to express their views about the service.

A complaints system was in place, supported by an up-to-date complaints policy and procedure, which was also displayed within the home to support accessibility. The service maintained a complaints tracker to monitor and respond to concerns, ensuring issues were recorded and followed up appropriately.

People and relatives told us they felt comfortable raising concerns with staff and confident these would be addressed in a timely and appropriate way. This demonstrated that concerns were listened to and acted upon in practice.

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

Records showed people were supported to attend healthcare appointments, and a range of healthcare professionals visited the service regularly. Appointment outcomes and guidance from professionals were recorded in care plans, and staff followed these instructions in day-to-day support, helping to ensure continuity of care.

People told us staff supported them to access care and treatment, with arrangements planned in advance to meet individual needs. One person told us they had recently attended an eye hospital appointment for a sore eye and that staff always accompanied them to appointments. Another person told us staff had arranged and supported them to attend a audiology appointment due to concerns about their hearing. This demonstrated consistent support for timely access to healthcare.

Staff described positive outcomes for people and gave an example of a person who required dental treatment involving tooth extraction. Staff worked in partnership with healthcare professionals to support attendance despite the person’s known anxiety and history of refusing appointments. Staff successfully supported the person to attend the procedure with minimal distress and impact on their wellbeing, demonstrating effective coordination and personalised support.

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.

The provider had an equality and diversity policy in place and promoted a welcoming and inclusive environment for both people and staff, regardless of sexual orientation, gender identity or gender expression. Staff had completed equality and diversity training, supporting a consistent understanding of inclusive practice across the service.

People were supported to access the community and take part in activities of their choice, with preferences clearly recorded in their support plans. Where people required additional support due to physical or health-related needs, the service adapted its approach to ensure equal access to experiences. For example, 1 person with a physical disability was supported with appropriate mobility aids to enhance independence and participation. The person expressed a wish to go swimming, and staff worked in partnership with an occupational therapist to enable this in a safe and supported way, despite the additional risks involved. This demonstrated proactive, person-centred and partnership working to reduce inequality and support positive outcomes for people.

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.

Staff had completed training in end-of-life care and demonstrated an understanding of how to support people appropriately and sensitively at the end of their lives. This supported them to respond to people’s needs in line with their wishes and preferences.

People’s future wishes were recorded in their care plans, including preferences for end-of-life care where this had been discussed. This ensured staff had access to information to guide care and support decision-making in line with people’s choices when needed.