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Archived: Outreach Services Good

Inspection Summary

Overall summary & rating


Updated 12 November 2015

We carried out an unannounced comprehensive inspection of this service on 16 and 23 January 2015 when we found a breach of legal requirements. The breach of regulations was because we had some concerns about the way medicines were managed and administered within the service.

We asked the provider to take action to address these concerns.

After the comprehensive inspection, the provider wrote to us to tell us what they would do to meet legal requirements in relation to medication management.

We undertook a focused inspection on 29 September 2015 to check that they had now met legal requirements. This report only covers our findings in relation to this specific area / breach of regulations. As such the report only covers the key question ‘Is the service safe? This is one of the five key questions we normally inspect; the others being, ‘Is the service effective’, ‘Is the service responsive’, ‘Is the service caring’ and ‘is the service well led’

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Outreach Services’ on our website at

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.

On this inspection we found that improvements had been made and that medicines were being administered safely. We had discussions with the staff about how further improvements could be made around some areas of good practice.

We found good examples where people had been encouraged and supervised to manage their own medication in a safe way so that their independence was respected.

Other medicines we reviewed were stored safely and were locked away securely to ensure that they were not misused.

We asked about people who were on PRN [give when needed] medication; for example for pain relief. We found clear care plans had been drawn up to include supportive information for these medicines. The importance of a PRN care plan is that it supports consistent administration and on-going review.

There were no people being supported to take medicines ‘covertly’ [without their knowledge in their best interest]. We saw, however, that the services medication policy made reference to this and covered areas of best practice including reference to people’s rights under the Mental Capacity Act 2005.

We reviewed one person who was being treated with a medication supplied by the Community Mental Health Team [CMHT] and was being monitored by them. The service liaised with the CMHT to support the person.

Staff we spoke with were knowledgeable regarding the medicines administered to people. Staff told us they undergo training to ensure they are safe to administer medicines. On this inspection we saw three staff files which contained a record showing staff had been directly observed by senior staff and recorded as competent and safe. This was an improvement.

We asked about medication audits / checks carried out by senior staff or managers. We were told that there are two regular audits carried out. The first was a weekly check made by care staff and included a stock check of medicines. This basic audit was supported by a senior management audit carried out at intervals by a manager responsible for overseeing medication policy.

Although we found improvements overall, there were anomalies with recording of medications which meant it was difficult to carry out an audit of medicine stock at the time of the inspection.

We discussed how best practice around recording could be achieved by ensuring the medication administration record [MAR] chart was used as the central recording of all medicines received, carried forward and administered. This would help ensure an easier and more accurate auditing process.

Inspection areas


Requires improvement

Updated 12 November 2015

The service was safe.

Improvements had been made and medicines were administered safely.

We made recommendations to further develop medication administration records [MARs] in line with best practice.

While improvements had been made we have not revised the rating for this key question. To improve the rating to ‘Good’ would require a longer term track record of consistent good practice. We will review our rating for ‘safe’ at the next comprehensive inspection.


Updated 12 November 2015


Updated 12 November 2015


Updated 12 November 2015


Updated 12 November 2015