Scalford Court Care Home

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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

During our assessment of this key question, we found concerns in the assessment, reviewing and planning of people's care and treatment, which resulted in a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You find more details of our concerns in the evidence category findings below. People's care and treatment needs were not always assessed, planned, reviewed and documented. Systems and processes for assessing and monitoring people's capacity to make informed decisions were not robust.

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.

The provider's ineffective systems and processes to assess people's needs placed people at risk of staff not fully understanding and having access to information about people's individual care and treatment needs. An assessment process to determine people's needs prior to moving into the service was not in place. People's known needs were not always supported by risk assessments or care plans. Care records were not always reviewed and updated in response to a change in circumstance or event. For example, a person who had been assessed at being at risk of falls had experienced a number of falls since moving into the service. We found the person's care plan and risk assessment had not been reviewed and updated to mitigate the risk of further falls. The registered manager said they attended the daily handover meeting with staff, which provided them with an opportunity to share and discuss information as to people's care and treatment needs. The registered manager told us they reviewed a couple of care files each month, however, there was no record of this. The registered manager advised they were in the process of implementing a care plan audit tool.

Visiting professionals raised concerns about communication with staff and the management team, which included how recommendations relating to people's care needs and treatment were not always implemented. The registered manager told us there was no formal pre-assessment process, and that the managers assistant took referral details over the telephone and asked questions. However, the records of a person who recently moved to the service did not include any pre-assessment information and when asked, the registered manager did not know where the assessment conducted via the telephone was located. The registered manager advised for those people whose care is funded they relied on the assessment undertaken by the funding authority. Stakeholders told us they were working with the provider to bring about improvement to the quality of people's care records. Staff said the guidance in people's care plans was sufficient and were kept up to date by the senior care staff. Some staff said they did not always have time to read care plans but sought guidance from senior care staff. Staff told us they got to know people's individual care needs by spending time with them, getting to know them and asking about their preferences and routines.

People were not aware if they had a care plan and were unable to tell us if they had been involved in a pre-assessment prior to moving to the service. People could not recall if they had participated in meetings about their care and treatment. People said they were generally understood by staff, who were aware of their care needs, routines and preferences. Relatives confirmed they had not attended any meetings to review their family member's care but said senior care staff advised them of any updates or changes in care needs, including medicine changes.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

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.

People said they felt safe and had no restrictions placed on them. A person told us. "I have no concerns."

Staff had a basic knowledge of consent to care and treatment. A staff member told us if someone didn't have full capacity to make decisions for themselves, family an advocate or senior carer would make a decision on their behalf.

We found the the provider and registered manager were not consistently working within the principles of the Mental Capacity Act 2005 (MCA). There was limited oversight and monitoring of Deprivation of Liberty (DoLS) conditions and in some instances conditions were not being met. This had the potential for unnecessary restrictions being placed on people. The registered manager said the team leader and managers assistant completed MCA's; however, there was no formal oversight by the registered manager or provider. Processes to ensure staff undertook training were not effective. The staff training matrix showed a high number of staff had not completed MCA and DoLS training, and there was no evidence to support staff competence was assessed to ensure staff had the necessary understanding and knowledge. This placed people at risk of not having their rights upheld.