HF Trust Cheshire

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

The provider had failed to ensure all people using the service and those lawfully acting on their behalf, had given consent before any care or treatment was provided. We observed capacity assessments were out of date. People and their relatives were not involved in assessments around their care, meaning their contribution could be missed. People were not put at the heart of every decision relating to them; therefore, their rights were not protected due to staff not understanding the principles of the Mental Capacity Act (2005). Records around mental capacity and best interests were not present, out of date or had only just been created. Staff lacked training to be able to fully communicate with people especially when they were non-verbal, not all staff were using peoples i pad devices to aid in communication and lacked training in using Makaton which is a communication method that uses signs, symbols, and speech to help people with disabilities or learning disabilities express their wants and needs.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Feedback from relatives was mixed. Some family members shared they had been involved in care planning and were in regular contact with the deputy manager and praised the staff highly for their constant updates and communication with them. They felt confident they were made aware of everything they need to be to ensure [person] has the best possible care. However, we found families were not always invited to be involved in the assessment or care planning of their relations. One person stated they had not been invited to take part in any reviews and as far as they were aware there had been no reviews. They stated that despite initiating discussions about their relations’ support; they felt their requests had gone unheard. Another relative said they were not included in care plans and “I don’t get to see a care plan.'' We were also told, ‘’[Person] struggles with communication and the current staff changes will be adversely affecting staff ability to know how [person] communicates through their body language and facial expressions.''

Staff views on care plan reviews were mixed. These included: “They were not having reviews that they were aware of.'' “I have just been updating care plans with support.'' Staff shared, “Management usually sorts out care plans.'' Managers views in discussions stated, ''Care plans are templates, they have started to become a little more personalised. More work is needed and care plans for specific conditions is needed.''

Two assessments for people had been made since CQC’s last inspection in 2020. Initial assessments for people relatively new to the service were in place but information needed to be expanded further. One person was identified as having diabetes but did not specify the type, health implications, support, and not been recorded into the person’s nutritional assessment. Statements were made in respect of various everyday life and then a conclusion made there was no need for a mental capacity assessment to be done in each of these. There was no rationale for this decision. The contents of assessments were vague in places, for example, one person was recorded as “[Name] can have his moments like we all do". One person was assessed as experiencing anxiety when routines changed but this offered no indication how this manifested itself or what support could be needed. The assessment included an opportunity to record observations of people’s lives/needs at their then current address. In both cases this was not completed. This meant people were at risk of not fully having their needs explored. Communication plans were in place based on the skills of each person supported.

One person told us they prepared drinks and light snacks for themselves with staff support if needed. They were happy with the food available to them. Families had mixed views in relation to nutrition and hydration and said ''[Name] does their own shopping. They tend to buy unhealthy snacks. The relative had tried asking staff to help them to buy ingredients for a meal they could prepare for themselves and this could be a positive activity for them. however, this hasn't happened.'' One relative had asked staff to encourage [name] more to make healthier food options as they were making unhealthy choices now which were adversely affecting their physical health. However, it was acknowledged they respected [name’s] capacity to make their own choices. Another family member said ''Her diet is not particularly healthy, it could be more nutritious. She has put on weight. I have given healthy option ideas but change of staff means no consistency.''

Staff were able to give an account of the nutritional needs of people, particularly those with complex needs. This information included the levels people had been assessed for to reflect their dysphagia. Staff were aware of SALT assessments had been conducted as well as people’s preference in foods they enjoyed or disliked. Staff did demonstrate a commitment to ensure the well-being of people through their interactions with them. Staff told us that they did have training in nutrition, some of it was deemed unnecessary as we trained in matters people did not have or needed, it felt like a distraction.

The presence of SALT assessments in support plans where applicable was not consistent. We observed people assessed as being at risk regarding choking but no record of action taken. Information was found to contradict care plans as indicated no issues with choking for some people when screening information stated otherwise. We found inconsistencies with the screening where people were at risk of choking but no referrals made and incomplete information on support plans to give staff an indication of the needs of the persons support regarding nutrition support. No reference made on hospital passport to nutritional needs for some people. The auditing of care plan and oversight was not picking up on the fact it was not evident on care plans sampled who was involved in them, if people were at the centre of their care planning, if families and professionals where applicable involved. It was not evident professionals were involved in creating support protocols such as Epilepsy. It was evident from sampled PBS plans the sections to add who was involved were left blank and staff signatures were not apparent to state they had read and understood the plans. It was not evident how often the care plan was reviewed and how often as the most recent date was the only one viewable.

There were mixed comments from relatives in respect of effective teamwork, these included comments on how information was passed on to relatives. One relative said, “Staff aren't working well together and there is friction amongst some of them. I can feel this when I visit so it is likely service users are aware too. There hasn't been any team building or in house training for staff that I am aware of.'' Another comment made was ''Staff do work together to support [name] as best as they can.'' Another family member told us ''There is no communication. I would like better communication.''

Staff told us handovers were mainly verbal for key information to be passed on. One member of staff said since handovers were verbal, it was difficult to find information after they had returned from annual leave or days off. Staff told us there had been so many changes at senior management level and their roles in the organisation that they did not know who was and had not met them. This meant communication from senior management was not always effective. Staff stated they should be having house meetings, that were not happening and, ''It's not a robust process of a handover, just word of mouth.''

Partners told us there had been a lot of changes in the management. As a result, when partners had requested information from the provider, this was not always provided. Partners confirmed staff were unsure as to who was the manager at any one time. Staff had sought advice and guidance from partners as the management team were not communicating with support staff effectively.

Recorded handovers for two services were sampled. In some cases, handover records were not available,had not been completed or had not been dated. There was no section included to comment on the general well-being of people, merely to record any significant incidents, if they occurred. Staff meetings were not held to a set frequency and included a list of items discussed rather than included a plan of action for when tasks needed to be done and by whom. One set of minutes stated, “Nothing is being handed over verbally to staff coming onto duty which affects how the service runs. We may need a communication book for the house”. There was no indication as to whether this had been actioned. One service had not had a recent team meeting. The last one was in November 2023. A list of actions had been recorded but with no indication of who was responsible or when they should be done. Correspondence was in place for some medical appointments and outcomes relating to consultants and speech therapists. Hospital passports for two people devised by the provider were missing key information on consent and nutritional needs. One person did not have reference in their passport to dysphagia and the support required for this person to eat.

People who could, told us that if they were unwell, they could see a doctor although they were general keeping well. Relatives told us they were not always consistently involved in attending their relations’ medical appointments or in gaining information from staff following appointments for an outcome. Some families told us they felt they were kept informed of anything they needed to be, and they felt confident that they were made aware of everything they need to be to ensure their relation had the best possible care. One person said, ''I do not go to the GP, but staff are good at passing on concerns.'' Others told us, ''I am not told about GP appointments, but I do receive feedback. However, I would like to attend.''

Manager commented that progress in health and other outcomes should be undertaken at their review meetings, which have not been taking place. Staff told us people are supported to attend appointments and many family members did support their relatives to appointments.

People were registered with a GP and evidence was in place to suggest there was contact with other relevant health professionals. Health appointment records, in some instances, were not always fully completed on the system after attending an appointment and outcomes and aftercare following appointments were not always recorded. Yet in other cases, they were completed. Paper copies of health appointment records were blank in one service. All care plans included details of key medical professionals that people had contact with associated with their health conditions. Another person’s recent admission to hospital with sepsis was not reflected in their care plan and preventative care was not considered. People had care plans in place but these often lacked detail to enable staff to support them to live healthier lives. For example, where people had health needs such as diabetes, information relating to the type of diabetes and the persons nutritional assessment had not been completed. People had hospital passports to enable them to attend hospitals safely, but these did not include crucial details about the persons food and fluid needs and mental capacity. People were not always supported to eat healthily, and families raised concerns regarding diet and a lack of exercise.

Relatives presented a mixed view of outcomes for their relations. These included, ''I feel that [name] isn't given enough opportunities to encourage their independence.'' and ‘’Drivers are not recruited, and this means [person] can’t do their activities.'' And another family member said, ''I would like them to be more involved in preparing meals and doing jobs around the house, they enjoy cooking. Another family member said, ''The staff do promote [Name] independence as much as they can, but current financial restrains make this more difficult.'' One person told us they wanted to move to a new city to be nearer to their roots. This process was being done by a senior manager, but they had left the service and there was no indication as to whether this person’s aspirations will be continued or pursued.

The manager commented. ''In respect of monitoring the outcomes for people, only through the effectiveness of the staff talking to people, the key worker side of things need to get better to improve things. Staff having conversations, ideally to have monthly meetings to look at these.'' Staff told us ''Since I have started the focus has been on shift cover and the rota, I have not had the time to review documents and the audits, I am pulled back to the office as we have so many shifts outstanding.''

People's outcomes were not always clearly recorded or acted upon. There were forms for people's goals, however, these were blank. People's care plans did not outline support towards obtaining independence or the monitoring and outcomes of goals important to them. Monitoring of people's food and fluid outcomes were often incomplete. Outcomes following people's health appointments were not always recorded, making it unclear what follow up action needed to be taken. Where people had health conditions, these were not always monitored, risk assessed or reviewed to ensure people received effective care and treatment. We saw limited involvement from people and their families into the setting and monitoring of goals and outcomes. Support plans did not confirm that there is an ongoing process of reviewing the aspirations of people to create more independence. The future development of people was not reflected in care plans as there was a sense that staff were striving to meet current needs rather than monitoring any progress.

People were consulted with by staff on day-to-day issues such as what they wanted to do. Relatives told us, “[Name] has been supported there for a long time and I am sure consent was spoken about then”.

One person did not have any family or significant others. Staff were asked about whether they had an advocate. They said they did, but no evidence could be found to confirm this or frequency of contact. Staff told us, ''We support people who do not have capacity to support decision making and we are fortunate we have people who have family support and sadly some do not and we get appointee of advocacy support and professional support.'' Other staff struggled to give examples of when they ensured people consented to their support.'' One manager told us they had only just introduced the support of advocacy into services.

The provider was not working in accordance with the Mental Capacity Act 2005 and associated code of practice to ensure people’s rights were being meet. Mental capacity assessments did not include full consultation with families in best interest decisions. Minutes of meetings assumed the consent of family members and others in key decisions made without formal consultation. We observed capacity assessments to be out of date and not reviewed regularly for people to also include best interest processes. This was a breach of regulation as already addressed in the safe key question.