People and communities have the best possible outcomes because their needs are assessed. Their care, support and treatment reflects these needs and any protected equality characteristics. Services work in harmony, with people at the centre of their care. Leaders instil a culture of improvement, where understanding current outcomes and exploring best practice is part of everyday work.

Everyone is supported to see what works well and not so well based on indicators of quality. Continuous improvement is always guided by this insight.

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Monitoring and improving outcomes

• We work with people to identify the personal outcomes they want to achieve and how this will be done and measured.
• We ensure that people’s care enables them to achieve the best quality of life possible, including emotional wellbeing, physical wellbeing, interpersonal relationships, social inclusion, personal development etc.
• We can evidence how we undertake regular health reviews and monitor the changing care needs of each person we support.
• We can evidence how we have adapted care in response to the changing care needs of each person we support (e.g., end of life care, challenging or distressed behaviours etc.).
• We can demonstrate how we are helping people to meet clinical expectations and recommendations in their Health Action Plans.
• We actively involve people in decisions related to the monitoring and changes to the care they receive. This includes where appropriate involving family, friends, and advocates.
• Our managers and staff teams are trained and assessed to ensure that they can effectively monitor people’s changing needs.
• Our quality assurance processes enable us to identify both individual changes to people’s care needs and emerging trends. This information is used to respond to both individual needs and address areas for improvement.
• When available, we use digital record systems to monitor changes to people’s care needs and emerging trends.
• Where needed, we’ll make referrals to appropriate healthcare specialists and securely provide accurate information to help them to inform further support.
• We support people to access the healthcare support they need including health screenings, opticians, dental appointments, etc.
• We ensure people’s weight is regularly monitored and record the results (if appropriate to their care needs). If we identify issues, we’ll advise and support the person.
• We advise, support, and try to protect people, including those with complex needs, from the risk of poor nutrition, swallowing problems and other medical conditions.
• Where needed, we’ll make referrals with consent to, diabetes nurses and other healthcare specialists to ensure best practice around food, nutrition and hydration is provided.
• Our close connections with other services enable us to benchmark the care outcomes of the people we support with similar needs of other services.
• We can evidence how our focus on monitoring and improving outcomes has reduced hospital admissions.

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