Community Outreach received an overall rating of Requires Improvement following a focused inspection of safe, effective, and well-led domains, with breaches of Regulations 12 and 17 identified relating to unsafe medicines management, inadequate risk assessment, insufficient staff training, and ineffective governance. Strengths included robust safeguarding systems, consistent staffing, good infection control, and an open and honest nominated individual committed to improvement.
Concerns (11)
criticalMedication management: “Medicines were not safely managed. A medicines policy was in place, although this was not being followed.”
critical
Medication management
: “Medicines audits were not robust...Audits failed to adequately review medicine administration records and documentation.”
criticalCare planning: “Where staff had to support a person with a catheter, there was no care plan in place to guide staff in how to safely support this person.”
criticalStaff training: “6 staff not having medicines administration training or an assessment of their competency to safely administer medicines, 4 staff not having life support training.”
criticalGovernance: “Quality assurance systems were not effective in identifying issues and improving the service.”
moderateStaff competency: “Staff received medication training but did not have their competency checked. Annual competency checks are best practice to ensure staff are safe to administer medicines.”
moderateSupervision / appraisal: “Staff supervision and support was inconsistent and did not meet the needs of all staff. Overall staff said they felt 'unsupported'.”
moderateLeadership: “The manager had limited oversight of the day to day running of the service. There was an over reliance on senior staff members to run the service.”
moderateIncident learning: “Systems to monitor accidents and incidents were not effective and did not promote learning. Audits did not fully consider any emerging trends or themes.”
moderateRecord keeping: “Records of care and support were not accurate or up to date...we were unable to identify if people had received the care and support they required.”
minorConsent / capacity: “Records did not always demonstrate people, or their legal representatives had consented to their care.”
Strengths
· People were safeguarded from the risk of abuse with effective systems for prompt action on safeguarding concerns.
· Appropriate recruitment processes including DBS checks ensured only fit and proper staff were employed.
· Effective infection prevention and control measures; staff wore PPE consistently.
· People were supported to eat and drink enough to maintain a balanced diet.
· People were usually visited by the same staff who knew their needs and preferences.
Quality-Statement breakdown (14)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks, and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: How the provider understands and acts on the duty of candourGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Continuous learning and improving care; Working in partnership with othersRequires improvement