Cornerstones Extra Care Scheme

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

People felt they were not always involved in reviews of their care and support, however they stated they received care that was based on their individual needs. People were supported by staff to access care and treatments from other services and professionals. Staff used evidence based tools to monitor people to protect them from risks such as pressure ulcers, malnutrition and dehydration. People were supported to have maximum choice and control of 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. Staff understood the principles of the Mental Capacity Act and applied these in practice.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they received care and support which was based on their assessed needs, adapted as needed and involved input from relatives and professionals where needed.

The nominated individual told us the provider used a robust assessment process used to provide staff with a full picture of people, not just their care needs. They told us people, their relatives and advocates were involved in the assessment process where appropriate and care plans were reviewed 6 weeks after a person started using the service then as often as needed. Staff told us they fed back to their managers if they observed people’s needs had changed as part of the continuous assessment process.

The provider used an electronic system to store all care plans and risk assessments. Care plans contained evidence of updates and reviews. However, we could not see evidence of people’s care plans being reviewed after 6 weeks or at regular intervals. In addition there was a lack of evidence to show people had been involved in reviews of their care.

People gave us mixed feedback about whether the told us they were involved in the planning and review of their care. One person said, “My care needs were discussed with them when I came here about 18 months ago. As things change for me, I speak to the care co-ordinator and they take changes on board”. Another person told us, “There is a care plan and in the past and after a stroke it was properly reviewed. I was involved and the changes were put into action”. A third person said, “[Staff] have a plan. I wasn’t really asked. When I got worse I got a hoist and a hospital bed. I’m not sure if there was a review” and a fourth person told us, “I think there is a plan but recently I haven’t been told of how things are going”.

Staff were aware of people’s needs and knew when to raise concerns with management if they observed deterioration in people’s health or wellbeing. They gave examples of tools they used to manage pressure ulcers and swallowing difficulties. One staff member described supporting a person with a pressure ulcer. They said, “One [person] came home with a pressure ulcer… the district nurse came and dressed it. We make sure it’s always clean…reposition [person] all the time”. Another staff member described how they supported a person with swallowing difficulties, “[Person] always had issues with swallowing…we used a food and fluid chart and the [speech and language therapy] team were involved…at lunch we sit with her and watch her eat”.

The provider had policies in place which were linked with current legislation. However, there was a lack of evidence to demonstrate the provider used processes to monitor the delivery of evidence based practice. The registered manager had not completed any audits in this area and there was no evidence in the regional manager’s monthly visits to demonstrate this was being monitored by senior leaders. In addition there was a lack of evidence of evidence based tools being included in people’s care plans or recorded elsewhere for staff to refer to when delivering care and support.

People told us staff worked with professionals to share information about their health needs. Comments included, “[Staff] phoned the hospital. The hospital phoned me to check if it was alright to share my information with the carer. I said “Yes” they could share my information”, “The carers know my GP and can share information and they don’t go behind my back. It’s all kept confidential” and, “I ask them to inform me before they contact others (professionals), so there’s no mix up or confusion. They keep their word on that".

Staff told us they shared information about people with professionals as needed, for example when making referrals for additional care or support. Staff reported they liaised with occupational therapists, speech and language therapists and GPs. They ensured recorded information was accurate and up to date.

Professionals reported staff shared relevant information about people’s needs.

The provider maintained detailed records of interactions with health and social care professionals on people’s behalf. There was evidence of referrals to healthcare professionals and communications with them regarding changes in people’s needs.

People told us they were supported to access the care and support they needed to live healthier lives and have positive health outcomes. People were able access support and treatments from healthcare professionals and staff helped them maintain their independence.

Staff had a clear understanding of how to support people’s health. They told us they did this by encouraging people to retain functional and mobility skills to support them to remain as independent and as healthy as possible.

People’s care and support records documented the type of support they needed to help them maintain their functional skills and independence. They also included details of support required from health and social care professionals.

People told us staff were responsive to changes in their needs and made changes to their care and support as needed. People’s comments included, “There is a care plan…after a stroke it was properly reviewed. I was involved and the changes were put into action” and, “The carers know all about the care changes…my changing needs were discussed”.

Staff told us they continuously monitored people’s health and wellbeing to ensure they had positive outcomes. They described using food, fluid and pressure ulcer monitoring charts to help protect people from the risks associated with dehydration, malnutrition and pressure ulcer damage. The nominated individual told us they worked closely with people, their family members, advocates and health and social care professionals to maintain a clear picture of people’s goals and outcomes.

A number of recording methods were used by staff to monitor people’s risks of malnutrition, dehydration and the risk of developing a pressure ulcer, for example. However, there was a lack of evidence to show this information was being used assess people’s risk of deterioration to inform actions staff should take to prevent people suffering harm. For example, we could not find evidence in people’s care plans the information from monitoring had been used in reviews of people’s care.

People were supported to have maximum choice and control of 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’s comments in this area included, “[Staff] are always asking before they do things in my home…verbally and in writing…they don’t do what I don’t want to do, but will gently coax”, “[Staff] will respect if I want not to do something…if I wanted a lie in” and, “Yes, the [staff] ask first. They ask me if they are not sure of something and ask for more information if I need more support. We work things out between us. They ask before I have a shower and check if the water is warm enough and what shampoo I want”.

Staff told us people were supported in line with the principles of the Mental Capacity Act (MCA). Staff had received training about the MCA and understood how to apply this when providing care and support. One staff member told us, “Everybody has a right to refuse or decline things…you have to communicate with them…you have to reassure them they have the right to refuse...it’s their choice”.

Care plans contained consent forms signed by people. The provider had processes in place for recording information and communicating changes in care needs for people who had legally appointed representatives who held lasting power of attorney.