Care & Grace

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

Systems were in place to gather information regarding people’s health and care needs prior them being supported by the service. However, people’s care plans did not always reflect the information gathered. Risk assessments and information regarding people’s health care needs had not been put in place which would identify potential risks to people’s health and well-being and provide staff with the necessary information to support people safely and effectively. People were supported to access a variety of healthcare services and, on the whole, spoke positively about the care and support they received from staff and had no concerns. Systems were not in place to monitor and mitigate the risks to people. Accidents and incidents were not recorded which meant opportunities to learn lessons from these events were lost. People confirmed staff obtained their consent prior to supporting them.

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.

People and their loved ones told us they were fully involved in a pre-assessment process prior to them receiving support from the service. They told us they were confident their individual needs had been appropriately assessed and were fully understood. Despite not being involved in regular, formal reviews of their care, people and their loved ones reported they were in regular contact with the provider and any changes in care needs were shared and acknowledged. A relative told us, “I was fully involved in the care plan and have a copy of it.” They went on to say, “The first couple of months [provider’s name] went with carers every day so they could see all the signs due to [person’s] medical condition.”

Staff reported they were made aware of people’s care needs, directly by the provider and then through reading people’s care records. However, care files seen did not reflect some important information about people’s individual needs and risks that people had shared with us. This meant staff were not always provided with up-to-date information regarding people’s care needs.

Pre-assessment information was not available in people’s care files and. for 1 person, information regarding their particular health care needs met by another service, was not included in the care plan. Despite people telling us they were involved in reviews of their care, there was no evidence in people’s care records to demonstrate these meetings had taken place and their care records updated accordingly. For example, for 1 person, their care record noted how important it was for them to be supported to have regular contact with a particular relative. However, during the assessment we were told this relative had passed away. The person’s care plan had not been updated to reflect this important change.

On the whole, people told us they were very happy with the help and support they received from the service and were assisted to access healthcare services as required. A relative described how staff were always present when the GP visited their loved one and took note of their visits and actions that needed to be taken, for example obtaining antibiotics for a person. One relative had raised concerns directly with the provider regarding a member of staff failing to support a person in line with their agreed care needs during a mealtime. They reported the provider responded immediately to this concern, to their satisfaction.

Staff confirmed they supported people to access healthcare services as required and worked alongside other health professionals to meet people's needs. A member of staff told us, “I have a good relationship with the district nurse. If I thought there was a problem, I would call them.” Another described how they supported a person to attend regular hospital visits.

Care plans and risk assessments were not in place to provide staff with information regarding people’s particular healthcare needs, including their nutrition and hydration needs. Although staff were knowledgeable about some aspects of people’s health and care needs, there were gaps in their knowledge due to risk assessments not being put in place. This placed people and staff at potential risk of harm. For example, information was missing in 1 person’s care records regarding a food allergy. The provider rectified this and bought this to staff’s attention as soon as they were made aware of this during the assessment.

People, their loved ones and advocates told us staff supported them to access healthcare services to meet their needs. They described support accessing GP services and attending hospital appointments. One relative described how staff knew their loved one well enough to recognise when they were unwell and would contact them directly. They told us staff would collect prescriptions and ensure they were present for GP appointments.

Staff reported positive working relationships with their colleagues and other healthcare professionals. The small staff group told us they would speak to a senior member of staff or the provider if they had any concerns or needed to pass information on. People were supported by a consistent group of staff who shared information with each other.

We received a mixed response from healthcare professionals involved with the service. One told us, “They [the service] have been brilliant. It is a complex situation, they have been open and honest, and we keep each other in the loop staff have been supportive and build a really good rapport with [person]. They have been really helpful in gathering the information I need.”

Staff did not have access to sufficient information required in order to deliver safe and effective care and support to people. For example, risk assessments, that would provide staff with detailed information on how to manage the risks to people, were missing from their files. A relative told us staff supported their loved one with exercises they had been advised to complete by another healthcare professional. However, there was no information in the person’s care records that would provide staff with the correct guidance on how to support the person and no risk assessment that would identify the risks to the person and how to mitigate them. This meant the person was at risk of being supported inconsistently or incorrectly by different staff.

A relative described how well the provider knew their loved one and the signs to look out for if they became unwell. They explained the provider recognised subtle changes in their loved one’s health and would arrange for the GP and district nurse to visit where appropriate.

Staff did not have a sufficient understanding of people’s healthcare needs and the potential impact of these on their daily lives. Staff had not been provided with the most up to date information regarding people’s health care needs.

The service did not have systems in place to ensure risks to people’s health and wellbeing were consistently identified, assessed, managed and communicated to staff. People’s care records did not hold person centred information regarding their health care needs. The provider had failed to ensure staff were provided with information that would reduce the risk of harm to the person and to themselves and ensure continuity of care.

On the whole, people, their loved ones and advocates were happy with the care they received and felt they were supported by a group of staff who knew them well. A relative confirmed staff ensured their loved one had their medication on time, which was important to their physical wellbeing.

Staff were aware of people’s day-to-day care and support needs, and the general support they needed to maintain good health. However, staff were not sufficiently aware of people’s individual risks and the implications these had for their care. Staff confirmed they shared information with people’s relatives and advocates and worked alongside other professionals.

Risks to people had not always been explored and staff were not provided with the information to monitor and mitigate those risks to assess whether people were being supported safely and in line with their care needs. Despite staff telling us they would report any accidents or incidents, there were no records of these events. The provider failed to ensure people’s care and treatment was routinely monitored and opportunities were lost to learn lessons or look for any potential trends, placing people at potential risk of harm.

People, their loved ones and advocates confirmed staff obtained their consent before offering support to them. An advocate told us the provider would visit their loved one regularly, particularly if any concerns had been raised, in order to ensure their wishes and views were taken into account regarding the delivery of their care.

Staff understood the need to obtained people’s consent prior to offering support. The provider advised us 1 person had required information in a large print format and this had been arranged to ensure they fully understood what they were consenting to.

Despite people telling us they had been involved in planning their care, there was a lack of evidence in people’s care files to demonstrate this.