Dementia@Home

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

We assessed all the quality statements in the Effective key question.

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.

Relatives provided feedback to the provider that an assessment had been completed before they started using the service and staff had a good understanding of their needs.

The registered manager told us needs assessments were completed before people started using the service. The assessments were used to develop care plans and risk assessments with people.

The registered manager assessed people’s needs to make sure they were able to provide effective care. These assessments were used to produce people’s care plans. We found people’s care plans were standard across the service and not personalised. The same 3 identified needs were recorded which did not demonstrate the plans were specific to people.

Relatives told us people received the support they needed, for example, to maintain suitable nutrition and hydration.

The registered manager told us they worked together with specialist providers and the community health teams to ensure care was planned in line with current guidance and best practice.

Where people had common health conditions such as diabetes and epilepsy there was no guidance recorded for staff to follow. It was not clear what actions staff should take if the person became unwell or needed further support and treatment. The registered manager took immediate action during the assessment to contact appropriate healthcare professionals and seek advice and guidance. People’s records were updated with the guidance staff needed to provide effective care.

People told us staff worked well with other services, such as other care providers and community health services, to ensure they received the care they need.

Staff told us the systems for communication with other care providers and relatives worked well. Staff said communication was clear and information was shared where relevant.

Health and social care professionals told us the service had good systems to ensure teams worked well together to meet people’s needs. One professional commented, “The team is cohesive with respected and professional leadership. They communicate well and can provide seamless support both alongside and independent of other services”.

Staff worked with other care agencies and healthcare professionals to make sure people’s needs were met. There were good lines of communication between care staff working in people’s homes and management.

Relatives told us they were able to access health services, with support from staff where needed.

Staff supported people to access health services where appropriate. This included supporting people to attend hospital appointments and support to attend community health services.

Staff escalated any changes to people’s health to senior staff or with people’s family members. Action was taken to contact relevant healthcare professionals and make sure people had reviews if needed.

Relatives told us staff monitored people to assess whether any changes were needed with their planned care.

The registered manager told us people’s health was monitored to identify any changes. This was used to inform health professionals and review the care that people needed.

People had regular reviews of their care which included a review of their care plan. As the service was small, a consistent group of staff were working with people and reviewing their care. This helped to make sure monitoring was consistent and improvement was made where needed.

People were supported to have the maximum choice and control over their lives and staff supported them in the least restrictive way possible and in their best interests. People told us they were involved in decisions about their care.

Staff demonstrated a good understanding of the Mental Capacity Act and consent issues. Staff understood the need to follow the best interest decision making process if people were assessed to lack capacity to consent to a specific decision.

Staff had training on the Mental Capacity Act 2005. Records demonstrated staff were supporting people to make day to day decisions about how they wanted to spend their time.