The Outreach Service provides domiciliary care and support for people with learning disabilities who live in the community. Some people are supported in tenanted accommodation and others are supported at home with their parents and family. The agency is owned by Autism Initiatives who provide a network of support services for people with learning disabilities.
This was an unannounced inspection which took place over two days on 16 and 21 January 2015. The inspection team consisted of two adult social care inspectors and an ‘expert by experience.’ An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.
The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission 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.
We were able to speak with people at the two supported living locations we visited. They looked relaxed and had an obvious positive rapport with the staff members providing support. Those able to express an opinion said they felt safe with the support they received.
We saw that people requiring support when out in the community to ensure they were safe, had fully developed plans in place. Staff were arranged to support this depending on each person’s needs. People’s support plans evidenced this.
We asked about staffing for the service. Staff input was agreed depending on assessment and funding by social services. People commented: “There`s always enough staff on duty so yes I feel safe – and they are all very nice” and ‘’I look after my own medication but the staff are there to help me if I need any help.’’
We looked at how staff were recruited and the processes to ensure staff were suitable to work with vulnerable people. We looked at two staff files and found that appropriate applications, references and security [police] checks had been carried out. These checks had been made so that staff employed were ‘fit’ to work with people who might be vulnerable.
We saw that people’s medicines were reviewed on a regular basis. Some records we saw confirmed that people had been reviewed recently. We were told the competency of staff to administer medicines was formally assessed to help make sure they had the necessary skills and understanding to safely administer medicines. We could find no record of this on staff files however.
We found some anomalies with the medication administration records [MARs] which meant that they were not always clear and there was risk that some medicines might be missed. We found some people’s records difficult to follow as records were not clear. We did not find any evidence that people had not received their medicines. However, the medication administration records did not support a safe practice.
You can see what action we told the provider to take at the back of the full version of this report.
The staff we spoke with clearly described how they recognised abuse and the action they took to ensure actual or potential harm was reported. All of the staff we spoke with were clear about the need to report through any concerns they had. Staff told us; “I know about the whistleblowing policy and it`s there for a reason - I would use it if I had to’’, “One of the first things you do on induction is safeguarding training and I think I have got a review coming up soon.”
There had been a number of safeguarding referrals and investigations since our last inspection of the service. Agreed protocols had been followed in terms of investigating and ensuring any lessons had been learnt and effective action had been taken. This rigour helped ensure people were kept safe and their rights upheld.
Arrangements were in place for checking the environment to ensure it was safe. There were protocols in place so that staff at Outreach Services monitored the supported living environments and reported through any issues.
When we spoke with staff the main aim of the support was to encourage people to be as independent as possible and enjoy as full a daily life as possible based on people’s individual chosen lifestyles. We found examples where a person had been supported to achieve a range of activities to a level where they had become a paid trainer. Another person had been supported to get paid work at one service. The relative had commented, ‘’Doing his job has changed [person], he is so happy and settled and has more confidence.’’
We observed staff provide support and the interactions we saw showed how staff communicated and supported people as individuals. One person spoke with us and told us about a project they were involved in and how staff supported them to carry this out. We observed the person had good rapport with staff who supported them on a ‘one to one’ basis.
Relatives told us that staff seemed well trained and competent. We were told support staff appeared to have a range of life skills and were seen to be doing a very good job. Communication between relatives, people being supported and staff and senior management was efficient and effective.
We looked at the training and support in place for staff. We saw a copy of the induction for new staff and staff we spoke with confirmed they had up to date and on-going training. One of the house managers at a supported living house showed us the staff training matrix. This identified and plotted training for staff in ‘statutory’ subjects such as health and safety, medication, safeguarding, infection control and fire awareness. In addition staff had undertaken training with respect to the care needs of the people they were supporting. For example the induction training included Autism Initiatives five point ‘star’ framework to help understand people with autism. Also strategies had been taught on how to remain, and keep people safe whilst in the community.
Staff spoken with said they felt supported and the training provided was of a good standard. They told us that they had had appraisals by the manager and there were support systems in place such as supervision sessions and staff meetings.
We saw, from the care records we looked at, local health care professionals, such as the person’s GP, and Community Mental Health Team were regularly involved with people. One person we saw had been reviewed by a consultant psychiatrist very recently. Another person told us, “If we need to see a doctor or dentist then we can just see the staff and they arrange it for you – there`s never a problem you just ask.”
We looked to see if the service was working within the legal framework of the Mental Capacity Act (2005) [MCA]. This is legislation to protect and empower people who may not be able to make their own decisions, particularly about their health care, welfare or finances. Staff told us that time needed be taken to help ensure people were supported to make decisions. For example, we saw a ‘service user consultation’ recorded which evidenced how staff discussed care issues with the people they were supporting. This showed clear involvement from people in making key decisions about their care. We saw this followed good practice in line with the MCA Code of Practice. A staff member told us, “Myself and senior staff have all completed training around mental capacity.”
We discussed with staff and the people living in supported living how meals were organised. We saw that these were organised individually and people were encouraged to choose and plan their own meals. We reviewed one person who chose their meals using pictures and staff supported them to eat as healthily as possible. Another person we spoke with said, “We plan our own menus for the week, do our own shopping and cooking, get our own drinks so we very much do everything ourselves.”
Relatives spoken with told us they felt staff were caring in their role and supported people well. A relative said, “They deliver what is in the care plan. They listen to [person], his perception of life which is so different and give him the experience of meeting other people and being a normal person.’’ The staff we spoke with had a good knowledge of people’s needs and were able to explain in detail each person’s preferences and daily routine, likes and dislikes.
We saw that staff respected people’s privacy. They were careful to knock on doors before entering bedrooms and to respect each person’s space. One person said, “We have our own rooms if we have visitors – staff always knock before they come in so that`s nice.”
All family members and people spoken with felt confident to express concerns and complaints. Most people told us that issues were dealt with at reviews and the service was generally very responsive to any concerns raised. We observed a complaints procedure was in place and people, including relatives we spoke with were aware of this procedure. Some complaints were dealt with locally and a record made. Others were escalated to senior managers. The quality assurance manager showed us a file of all complaints received. We saw that these had been investigated and a response made.
All of the managers we spoke with were able to talk positively about the importance of a ‘person centred approach’ to care. Meaning care was centred on the needs of each individual rather than the person having to fit into a set model within the service. People using the service and relatives told us they felt the culture of the organisation was fair and open. It was evident that management had made visits or telephone calls to people using the service and their relatives to ensure needs were met. Assessments and reviews were conducted at the appropriate time. Overall relatives were pleased with the way the service was run.
We enquired about the quality assurance systems in place to monitor performance and to drive continuous improvement. The manager was able to evidence a series of quality assurance processes both internally and external to the service. There was a clear management hierarchy and we saw that new ideas and service improvements were effectively developed and communicated. This process also included input from people using the service at various points. For example there was a ‘service user forum’ to include views and opinions from people using the service.
The service was able to demonstrate areas of practice development to a high standard. For example, the organisation was an accredited ‘centre of excellence’ for specific training in understanding autism and supporting behaviours of concern. Other best practice was being developed jointly with an external educational institution to further develop the current sexuality and relationship policy for people using the service.
The service was keen to challenge and question areas of practice. The provider information told us, ‘Using information from current data for safeguarding, we can monitor and improve to strive to [reduce] safeguarding across services’. The week following our inspection the service was to receive feedback from social services following a recent safeguarding investigation. We were told that any findings would be fed into the various forums to discuss lessons learnt.
The theme of ‘service user’ involvement [of people using the service] was also exemplified by other management process, such as training and the recruitment of staff. For example, the organisation had encouraged people using the service to have input into the recruitment process. In some instances this involved people using the service siting on interviews. In other cases contributing questions.
Internally there were other key audits carried out to monitor standards in supported living houses. These included a ‘self-assessment audit, by house managers, the ‘peer to peer’ reviews and a ‘working file audit' also conducted by house managers. The area managers completed regular monitoring visits to each house.
The service also learnt from external audits and reviews. Any feedback was discussed at ‘management stakeholder meetings’. We saw the minutes of a meeting where the results and findings of social service contracts visits, some care reviews and unannounced visits [internal] to supported living houses were discussed and actions made.
The QA manager coordinated all of these processes and forums to produce a quarterly report for the national director. This included quality information and key performance indicators [measures of performance] including the Outreach Service.