Outreach Sefton Ltd was rated Requires Improvement overall following a focused inspection in November 2023, with breaches of Regulation 17 identified for failing to monitor care call attendance and medicines administration records. Responsive care was rated Good, with person-centred care plans and strong staff–client relationships noted as strengths.
Concerns (5)
criticalMedication management: “Changes in people's medicines care needs were not always updated on the medication administration records (MAR) in a timely manner.”
criticalMissed or late visits
: “There were no systems to alert the management team if a call was missed, running late or was shorter than the person's plan of care set out.”
criticalGovernance: “Systems had failed to identify the shortfalls regarding call visits and medicines.”
moderateRecord keeping: “Staff were not recording this correctly and there were numerous gaps on the person's MAR which suggested staff had not offered them all their prescribed medicines.”
moderateGovernance: “In recent months there had been some temporary management changes. During this period not all records had been submitted to CQC in a timely manner.”
Strengths
· People received person-centred care reflecting their needs, preferences, social and cultural interests.
· Consistent care staff attended, with people given prior notice of who would visit.
· Recruitment procedures were safe with pre-employment checks carried out on all staff.
· Risk assessments and care plans were developed to minimise risk to people's health and wellbeing.
· Staff felt supported, received necessary training, and spoke positively about working for the provider.
Quality-Statement breakdown (12)
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementGood
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongGood