Abihealth - Southwest Office

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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

We assessed 6 quality statements in relation to assessing needs, delivering evidence-based care and treatment, how staff and teams work together, supporting people to live healthier lives, monitoring and improving outcomes and consent to care and treatment. We found people were being supported by other services and professionals. Staff and teams worked well together. People’s care records demonstrated that professionals had been involved in their care and support. Staff showed a good understanding of gaining ongoing verbal consent from people. Care plans had signed consent from people and there were policies to support the service being effective. However, we found the provider had experienced challenges with getting information from professionals to complete assessments, care plans and risk assessment. Although assessments were being completed for people accessing the service, the information in care plans and risk assessments did not always guide staff to provide safe care and treatment for people. The service did not always have evidence-based tools embedded into their care planning system. The manager had taken steps to rectify these concerns during the assessment.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they had their needs assessed before support commenced and staff had a good understanding of their needs.

The care coordinator told us they “completed a new assessment for people who accessed the service. The information is gathered from a mix of professionals, service users and family.”

We found although assessments were being completed, information in care plans and risk assessments did not always guide staff to provide safe care and treatment for people. This was due to some information not being recorded accurately and conflicting information between care plans and risk assessments. We raised this with the provider, who took steps to rectify this during the assessment. They introduced a two-tier proofreading process and service user checklist as additional governance functions.

People told us they were being supported by various professionals within the community. They told us they received the support needed from staff.

Staff and leaders told us they worked with providers in the community to ensure care was planned for people. Staff mainly contacted the care co-ordinator or family if they had any concerns.

The service did not always have evidence-based tools embedded into their care planning system. The provider took steps to resolve this issue during the assessment.

Relatives told us staff would make contact if they needed to communicate anything about family members. One person told us the provider accommodated alternative visits to provide care when they had appointments with other professionals.

Leaders told us it was sometimes difficult to get information from professionals to set up people’s care plans in a timely manner. Staff had to chase professionals for the required information. This sometimes resulted in delays to people accessing support. The manager was committed to ensuring staff had all the information they needed to provide appropriate support to people. Staff told us the systems for communication with other care providers worked well. Staff contacted the office and communication with professionals was dealt with centrally.

The local authority’s quality team had worked with the service to bring about improvements. An action plan had been put in place following this support and improvements were evident in certain areas, although some still required further work.

Daily care notes did not always provide all the required information to be clear that people had their support needs met. The manager had also introduced additional workshops for staff across the organisation in relation to record keeping. The provider had an action plan in place and was taking steps to resolve this issue during the assessment.

People told us they were able to access health services, with support from staff where needed. Most people and their relatives told us they were able to address their needs independently.

Staff supported people to access local healthcare professionals. Leaders told us they worked with local authority quality and commissioning teams, social workers and various health professionals to help people live healthier lives.

People’s care records demonstrated that professionals had been involved in their care and support. There was evidence of people being supported to access relevant health services.

Most people and their relatives told us they had been involved in setting up and reviewing care plans. However, some people told us they had not been involved. People were able to view their information via the electronic care application so they could see all the relevant details of their care needs, daily notes and outcomes achieved.

Staff told us they relied on central office staff to update and make changes to care plans. The service had introduced a ‘social journey’ document for staff to discuss and reflect with people about their wellbeing. The discussions allowed people to focus on positive outcomes achieved. Leaders told us they had recently completed training with staff on record keeping, to ensure daily record notes were kept up to date and accurate. At the time of this assessment, the provider was working to embed this process.

Daily notes documented staff visits to people. However, we found the daily notes we reviewed did not always capture information in a concise way to monitor outcomes for people. The manager told us they were looking at developing processes around monitoring outcomes for people. They were looking at introducing case studies to highlight people’s care needs and journey, but this had not yet been started.

People told us staff asked for their consent and were respectful to their needs. Comments include “Yes, they give me a choice if I want to do something. Like what I want for breakfast or if I need help to go to the toilet or bath. I tell them if I don’t want to do something.”

Comments from staff showed a good understanding of gaining ongoing verbal consent from people. One comment was “I ask them all the time, even if it’s in the care plan, it might be different for them on different days.”

The provider had an effective process in place for seeking consent from its service users. We saw evidence of consent forms relating to 3 service users which had been appropriately documented and signed by the service user it applied to. There was evidence of a person refusing to sign the consent form and staff taking appropriate action to follow up with professionals. There was a consent policy in place.