Outreach Sefton Ltd

Updated 30 December 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

This inspection was carried out by 2 inspectors.

Service and service type

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

We gave the service 24 hours’ notice of the inspection. This was because we needed to be sure that the provider or registered manager would be in the office to support the inspection.

Inspection activity started on 10 November 2023 and ended on 29 November 2023. We visited the location’s office on 15 November 2023 and 21 November 2023.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We visited 3 people who used the service and 1 family member. We also spoke with a further 2 people who used the service and 1 family member on the telephone about their experience of the care provided.

We spoke with 4 members of staff including the registered manager, who was also the nominated individual, the clinical manager and care staff. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records. This included 7 people’s care records and multiple medication records. We looked at 4 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 30 December 2023

About the service

Outreach Sefton Ltd is a domiciliary care service providing personal care to people living in their own homes. At the time of our inspection there were 48 people using the service.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided.

People’s experience of using this service and what we found

Medicines were not always managed safely. Records were not always accurately completed when medicine support needs had changed or when people chose to refuse medicines. Improvements were also needed to the rostering system and the oversight of care calls to ensure people were receiving their full plan of care.

Recent changes in management arrangements had impacted on the quality of some aspects of the service. The provider, who was also the registered manager, was committed to making changes and had developed a clear plan to address any shortfalls.

Other aspects of people’s care were safe. Risk assessments and appropriate care plans had been developed to meet people’s needs. Staff were recruited safely.

People were involved in developing their care plans which were person centred and changes were made as people’s needs changed. Communication needs of people were identified. People’s social and cultural needs were also considered when developing and agreeing care plans.

Staff felt supported, told us they received the training they needed, and they enjoyed working for Outreach Sefton Ltd. The provider worked with other professionals and organisations to ensure positive outcomes were achieved for people.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

Rating at last inspection

The last rating for this service was good (published 16 January 2019).

Why we inspected

We undertook a focused inspection to review the key questions of safe, responsive and well-led only.

The inspection was prompted in part by the notification of a death of a person who used the service. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of pressure area care. This inspection examined those risks.

We found no evidence during this inspection that people were at risk of harm from the concerns about pressure area care. However, we did identify improvements were needed in other areas. Please see the safe and well led sections of this full report.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Outreach Sefton Ltd on our website at www.cqc.org.uk.

Enforcement

We have identified a breach in relation to effective management oversight at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.