Optimal Care Plus

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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 reviewed all 6 quality statements under this key question: 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 and consent to care and treatment. We found people were involved in their care and their consent to receive care, was sought by staff and the management team. Where people could not consent to care, people had a representative who was the agreed decision maker for more complex affairs. People had their needs assessed before care commenced and expressed how they wished their care to be delivered. People were supported to have their nutrition and hydration needs met where required. There were effective approaches to monitor people’s care and treatment and their outcomes.

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.

People’s needs were assessed prior to admission to the service. A relative told us, “The office visit and review [person’s] care package which I think is important and they are certainly hands on and I appreciate that.”

Staff had a good understanding and knowledge of the people they supported. They were able to tell us about the care they provided for people. One member of staff told us, “We [staff] know much about the client, as their assessment is completed, and their package starts. From there we can get to know as much as we can.”

The registered manager conducted the initial assessment of people’s needs prior to the commencement of their package of care. Care plans included assessment information, reviews of people’s care and updates to ensure staff had access to information to meet people’s changing needs.

People and relatives told us they were involved in the planning and review of their care. A relative told us, “I am involved in [person’s] care plan, they [staff] ask me if there has been any changes or improvements.”

Staff confirmed they had the skills and knowledge to carry out their roles effectively. They completed a range of training and told us information was disseminated to staff through supervision, team meetings, via the electronic care planner system and 1 to 1 discussion. The registered manager and 1 of the care coordinators held a train the trainer qualification and this enabled them to deliver training inhouse covering many subjects face to face.

Care plans contained evidence of involvement of a range of external professionals. There was guidance around people’s nutritional needs and people’s diets. Daily care records were monitored, and people received care, treatment and support that is evidence-based and in line with good practice standards.

People received support from both Optimal Care Plus and their relative/representative to access other health services to support their health and wellbeing.

Staff told us they have access to the information they need to appropriately assess, plan and deliver people’s care, treatment and support and would liaise with other health care professionals when required to.

We requested information from partners however, we received no information in response to our request.

The registered manager maintained records of interactions with health and social care professionals on people’s behalf where required and any changes to people’s healthcare needs were updated accordingly to record feedback and any actions or advice to be followed.

People and their relatives were involved in regularly reviewing their health and wellbeing needs where appropriate and necessary.

Staff understood the importance of people’s care and support being regularly reviewed and how good communication helped people to achieve good outcomes. Comments from staff included, “I ensure that the care is centred around the individual, provide high quality continuity of care, support people to make better lifestyle choices by providing resources and have open conversations about mental health. I encourage and offer emotional support and regularly assess and review an individual’s progress,” and, “I make sure the care I provide is person-centred, giving them both physical and emotional care, properly recording their progress.”

Records identified where people were at risk, for example, pressure ulcers, poor nutrition and hydration and poor medicine management. Guidance was provided for staff on how to support people to help promote and maintain their health and wellbeing and prevent further deterioration.

There were effective approaches to monitor people’s care, treatment, and outcomes. People received good outcomes because of the support provided to them.

Staff told us how they monitored people’s wellbeing to achieve the best possible outcomes. A member of staff told us, “I carry out regular reviews with people, I make sure staff study people’s care plans and information is updated also on the note facility in the care plan App. People’s care and support is adapted as changes arise.”

Care plans were reviewed regularly as part of the registered manager’s quality assurances processes. People and/or their representatives were involved in care reviews to ensure continuous improvements were made to people’s care and treatment when required.

People were supported to have maximum choice and control over their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People and relatives told us, “[Person’s] care is complex and extra support is needed to keep them healthy. They [staff] ask their permission e.g., can we lift you up is that ok. They always ask and treat [person] with respect,” and, “They [staff] engage well, they all seem sensible and are really good.”

Staff told us they had received training around the Mental Capacity Act (MCA) and were able to describe how they apply this in their day-to-day practice. Comments included, “We should assume everyone has capacity to make decision unless they have been assessed to lack capacity or if proven otherwise,” and, “The Act is a legal framework that helps protect people who cannot make informed decisions with the information provided.”

People's capacity and ability to consent were taken into account, and they, or a person lawfully acting on their behalf, were involved in planning, managing and reviewing their care and treatment.