Head 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 all quality statements within effective, and found areas of concern. The rating for effective has improved to requires improvement.

We identified two continued breaches of the legal regulations in relation to need for consent and dignity and respect.

Assessments of people’s needs were not always kept up to date. We found records often contained missing or conflicting information within them. The provider had not always followed the principles of the Mental Capacity Act which meant we could not be assured all decisions were made in people’s best interest.

Some people had been involved in their care planning.

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.

Some people were involved in the assessment of their needs. For example, one person had reviewed their care needs with their care manager. We read they had gone through a new assessment together.

However, other people told us they had not been involved. Due to the concerns we found with missing and conflicting information being recorded about people we could not be assured people or their relatives were fully involved.

A relative told us, “When they have a review we are asked to go, and we normally do go.” Another relative told us, “We haven’t had one (care review) in a while.”

Staff were not always clear on people’s needs. Some staff who were supporting people, did not know their life history and we observed staff did not always use the correct equipment when supporting people with mobility.

One member of staff told us, “I know not much about it as I am new to this house.” When asked about a person’s life history. Another staff member said they did not know any of the life history of [person] who they had supported at the service for the past 2 years.”

Partner agencies informed us that 3 people did not attend their pre planned health appointments, and that staff were not always following up on contacting a GP when a person had increased seizure activity.

Systems and processes were not robust in ensuring people’s assessed needs were documented to ensure staff could deliver safe care and treatment. We found missing and conflicting information regarding people’s preferences, routines, needs and life histories.

Systems and processes were not effective in ensuring staff understood people’s needs.

People were not supported appropriately in line with current evidence-based good practice and standards. As such people were at risk of declining health.

Staff had a lack of understanding of the guidance around Right Support, Right Care, Right Culture. Staff we spoke with did not always have a good understanding of how to monitor people’s health.

Systems and processes were not effective in ensuring evidenced based care and treatment was safety completed. For example, one person required weekly weighing and regular snacks offered to mitigate risks associated with weight loss. However, records evidenced their weight was taken once in November 2023, December 2023, January 2024, and April 2024. Their food records did not evidence 3 meals a day or that snacks were always offered. This put people at increased risk of weight loss.

People’s experience of attending their health appointments were not always planned well by staff. One person did not like attending appointments and as such it was written in their care plan that staff should call ahead to ensure the transition between his home and the appointment was smooth. However, upon review of their care notes, we found despite four appointments being recorded, there was no indication that staff had called ahead.

The registered managers told us, “We work with different teams to identify extra support that may be needed and work closely with families and professionals. When people have their reviews, we make sure that any partners (agencies) are involved in the review.”

We were told by professionals that when they went to assess someone, the registered manager did not give them correct information about the person’s needs. We were told, “Our experience has been disappointing, with [the provider] sharing inaccurate information of the client’s needs.”

There were processes in place for staff to make referrals to professionals when they assessed the person’s needs may have a changed. We saw a referral had been made for an occupational therapist (OT) assessment for one person following some falls. The OT recommended some adaptations which were ordered.

People were not always receiving care and treatment in line with professional advice which could put them at risk of harm. For example, one person’s care plan stated staff should contact their GP if they had 2 or more seizures, there was no evidence to suggest staff were following this guidance.

Relatives did not always feel staff supported their family member appropriately in relation to their health. A relative told us, " We have now said to Mitchell’s we will make [person] appointments which carers can take [person] instead of them doing it. I don’t know if they will follow the instructions, it was supposed to be in care notes but we will see.” Another relative told us, “[Person's] skin did get very bad recently and staff don’t appear to have taken [person] to the GP.”

There was a mixed response from staff on whether they knew and understood people’s health conditions. Whilst some staff knew and understood the impact of health issues for people, other staff lacked this knowledge.

We received feedback from healthcare professionals in relation to working with the provider. They told us they had identified issues with incorrect medicines being given to one person, three people missing health appointments and incorrect information being provided to them about another person.

Processes lacked robustness which meant when staff did not follow professional guidance this was not being identified. For example, one person had been advised by a professional to avoid certain foods as this had previously resulted in them being admitted to hospital. Despite this advice, when we reviewed daily notes from 1 May – 29 June (60 days) show, these showed on 24 days in May and 20 days in June this person had foodstuff that was on the list of foods to avoid.

People were not always supported to have improved outcomes. For example, despite staff contacting one person’s GP for advice regarding their health condition, they did not follow this up to see if further treatment could be arranged to help with this.

A relative said they had concerns with how their family member’s weight was being managed and another relative told us, “[Person] loves food, and in about 18 months [person] put on a stone and a half. We asked (staff) for a specific meal plan but we aren’t sure if this is followed. We have access to care notes but they (care notes) aren’t always complete.”

Another relative told us about some bullying behaviour between people living in a house. The relative told us they had not been informed and therefore, was unable to support their relative and sufficient action had not been taken by staff to look into why this may be happening. Another relative told us, they had to raise multiple concerns as staff were not able to communicate with the person.

The registered manager’s told us, “We identify what people want and support them to achieve this. For example, [person’s name] wanted to do an English and Maths course. We took it slowly and now they go to college.” However, due to the concerns raised to inspectors from relatives we could not be assured outcomes were being effectively monitored.

Processes were not sufficiently robust enough to ensure that monitoring of people’s health conditions was always being carried out correctly. We reviewed the records for people and found gaps in bowel monitoring charts and a lack of oversight where one person was being given their ‘as required’ medicine on a daily basis. This meant people’s health may suffer. People may not receive care that was safe because there were poor systems in place to ensure professional advice was embedded into practice by staff. One person was due to start probiotic drinks for two months, but there was no indication this instruction had been followed and this person’s care plan had not been updated to reflect this.

People were not always supported by staff in relation to consent and people's rights to make their own decisions had not always been respected. Some parents were making decisions on behalf of people without staff following the correct processes. This meant there was a risk of people not receiving care in line with the principles of the Mental Capacity Act (MCA).

We were also told by a relative that a staff member had entered their family member’s premises and removed items, without their consent.

Despite staff receiving training on the MCA and Deprivation of Liberty safeguards, management did not always check staff’s understanding or review processes to ensure that the principles were followed correctly. This meant some people may be having decisions made for them unlawfully. Some staff did not understand the MCA and their responsibility to ensure that they followed the correct steps to check someone’s capacity to make decisions. For example, staff told us how the parents of one person determined how they spent their money and the parents of another person decided on how their hair should be cut. The provider had not always carried out capacity assessments on these people or made best interests decisions to check that these decisions were in the person’s best interests.

The provider failed to implement effective systems to ensure the principles of the MCA had been followed.

When equipment was used that restricted people’s privacy or movement, mental capacity assessments and best interest decisions were not always in place. Records did not include if lesser restrictive options had been considered. This put people at risk of actions being taken/care given against their wishes and without their consent. This also put them at risk of not receiving person centred care.