Church Farm at Rusticus

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

People were not always supported effectively. Care plans did not always reflect people’s needs and choices. Where risks had been identified, care plans did not contain clear guidance for staff on how to support people to manage or mitigate those risks. However, external partners who worked with the service stated the registered manager was responsive to feedback and implemented their recommendations accordingly.

This service scored 62 (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 relatives did not receive a consistent experience regarding having their need assessed and care plans created. Some people told us they were included in their care planning and received regular reviews. Other people told us they were not included in this process and relied on staff giving them verbal updates. One relative said, “Staff do keep me informed but I don’t think I have seen [names] care plan or been part of their review.”

Staff told us that they had time to review care planning documents, so they could keep up to date with people’s changing needs and attended daily handover meetings which discussed people’s needs. However, staff and the management team acknowledged that some care plans required updating and were not always reflective of people’s current needs. We found no evidence that anyone had come to harm due to the concerns found in care plans as staff had good knowledge of how to support people’s needs, and what action to take if the person’s needs appeared to have changed.

The provider had a policy in place with guidance supporting staff to create a person-centred care plan. However, these guidelines where not always followed in a timely manner and did not always contain robust or accurate information. For example, one person who had several incidents of falls recorded had a risk assessment score of low that stated the person did not have a history of falls. This placed the person at risk from not having their need assessed safely. The provider responded immediately to the concerns we found on the assessment and undertook a full review of all care plans which included relatives or advocates where appropriate.

People and relatives told us that staff were knowledgeable about their conditions and supported them to understand information and different care pathways. One relative said, “Staff are really good, [relative] has dementia and staff have helped us as a family understand the different stages of the condition. This has helped us interact and care for [name].” However other relatives told us they had observed situations that had given them concerns about how people in the home were treated. One relative said, I have had to intervene and stop a resident hitting another resident, I told staff but nothing happened.”

Staff had good knowledge of tools that the service used, and how they impacted the care given. For example, one staff member explained that a malnutrition risk tool identified how likely a person was to be malnourished. However, staff told us care plans were not always up to date and it was their knowledge and experience of people that prompted them to use these tools rather than guidance in people’s care plans. Staff understood how to work with external health and social care providers, to provide support in the most effective way.

During the assessment we reviewed several care plans and found differing levels of written guidance contained within peoples care plans. For example, one person’s care plan identified them at risk of weight loss, there was clear guidance for staff on how to support people and when appropriate to give additional weight gaining supplements. However, we reviewed a care plan where the person had experienced several recent falls, and these had not been included within the care plan or risk assessment. This meant there was no guidance for staff on how to support the person to reduce their falls whilst maintaining their independence. Another care plan identified the person as being at risk if they did not receive a certain amount of fluids daily. However, the care plan did not detail what this risk was or provide any guidance on how staff could keep this person safe, for example by listing any symptoms that could be experienced through lack of fluids. We raised this with the management team who included these concerns in an immediate review of care plans within the home.

People told us they were supported to access other services as they requested or when needed. One person said “The hairdresser has been here today. They do nails too. We had the optician last week and I can see a doctor whenever I need.”

Staff told us about the weekly ward round undertaken by the GP and knew how to access support out of hours. Nurses told us they worked directly with professionals such as district nurses and occupational therapists to ensure people received person centred care.

We sought feedback from the partners with which the home worked with such as the local authority. Partners told us the register manager was responsive and followed up on recommendations made.

Processes had been put in place to ensure people’s needs were assessed and documented prior to being admitted to the home. We saw evidence of medical professional recommendations being recorded within care plans however these were not always followed. For example, one person was at risk of dehydration and required a daily fluid amount to mitigate this risk. We saw this target was missed consistently and no action had been taken by staff ,this placed the person at risk of harm. We raised this with the provider and management team who responded immediately and sought GP advice for the person.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Monitoring and improving outcomes during this assessment. The score for this quality statement is based on the previous rating for Effective.

Most people told us that staff sought their consent prior to assisting them with their care. One person said, “Staff always ask and tell me what they are doing, I can’t fault them.” However, where people lacked capacity, we were not always assured that staff were guided by care plans to continue to seek consent or that their relatives had been included. This concern has been evidenced under the key question of safe and through feedback from people and their relatives.

Staff told us they received training regarding supporting people to make decisions and consent to care, through training such as mental capacity and dementia. We observed staff offering choice and support to people in their preferred methods. For example, we observed staff offering people comfort breaks and support with their personal care or offering alternative times if people preferred.

Care plans contained mental capacity assessments and best interest decisions for people, however these were not always person centred or comprehensive enough to show where people lacked capacity. For example, a mental capacity assessment for one person stated they were not able to retain information they had been told after a period of time. However, the assessment did not detail the time frame or whether medical professionals or family had been included in the assessment. Therefore, we were not assured the assessment was reflective of the person’s needs.