The inspection took place on 27 June 2017 and was announced. We gave the provider 48 hours’ notice because the service was a domiciliary care agency and we wanted to make sure someone would be at the office to assist with the inspection. We visited people in their homes on the 28 and 29 June 2017.

North Locality – Berwick is provided by Northumberland County Council. It is part of the Short Term Support Service [STSS] which is managed in partnership with Northumbria Healthcare NHS Foundation Trust. It provides three distinct services; re-ablement, crisis intervention and a ‘bridging' service. Re-ablement concentrated on supporting people following a recent illness, hospital admission, or an exacerbation of a longer term condition, with the aim of getting them back to an optimal level of independence. The crisis intervention service supported those who required immediate support due to a sudden change in their circumstances such as an accident or acute illness. The bridging service supported people until a long-term provider was assigned.

At the time of the inspection, the service was providing care and support to nine people in their own homes.

There was a registered manager in post. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People, relatives and health and social care professionals told us that staff were exceptional in enabling people to become independent. This was confirmed by our own observations. People’s care plans documented every small step and improvement in people’s abilities.

People and relatives were extremely positive about the caring nature of staff. People’s care and support was planned proactively with them. Staff used inclusive ways of involving people so they felt consulted, listened to and valued.

People and relatives described the responsiveness of staff as outstanding. Health and social care professionals told us that the service was focused on providing person-centred care and it achieved exceptional results. One health and social care professionals told us, “They are an absolutely invaluable resource and service that we can link into. It’s a service you can access and it’s multi-disciplinary. It’s excellent.”

The service was exceedingly flexible and responsive to people’s individual needs and preferences. Staff explained they were able to be very responsive because times of visits were flexible. One staff member told us, “We have the luxury of time.” A number of research based assessment tools were used to ensure the best possible outcomes for people.

Various inclusive feedback systems were in place. Reviews were carried out once or twice a week by supervisors to monitor people’s plans of care and ensure they were happy with the service provided. People were actively encouraged to give their views and raise concerns or complaints. There was a complaints procedure in place.

People and relatives were exceedingly positive about the service. Comments included, “They really are the complete package” and “It’s outstanding.”

We found the provider’s integrated model of care facilitated hospital discharges, helped avoid unnecessary hospital admissions and reduced the number of people requiring long term care by supporting people to regain their independence.

There was a joined up approach to providing holistic care that met the needs of people. This was enabled by an integrated system of leadership to help ensure people experienced the best possible outcomes which was confirmed by people, relatives and health and social care professionals.

There was a strong emphasis on continually striving to improve. Numerous checks were carried out to monitor the quality and safety of the service and ensure that people were receiving exc