Fanshawe Avenue is a domiciliary care agency providing support with personal care to people living in their own homes, many of whom are older people. We carried out our on-site assessment on the 19 July 2024 and our assessment activity started on 10 July and ended on 2 August 2024. We found the service supported people in a way that was safe and person-centred around people’s needs. There were enough staff and robust staff recruitment procedures were in place. People were able to consent to their care and were supported to be as independent as possible and to make choices about their care and support.
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Outreach Support Services Limited was rated Requires Improvement overall at its first inspection in January 2018, with two breaches of Regulation 9 found due to pre-care assessments not being completed for most people and care plans lacking sufficient detail about personal care needs. The service performed well in safe, caring and well-led domains, with strengths in safeguarding, medicines management, staff supervision and a positive, open leadership culture.
Concerns (3)
criticalCare planning: “assessments of people's needs had not been carried out prior to the provision of care and care plans did not contain information about how to support people with personal care needs”
criticalPerson-centred care: “care plans were very basic and lacked personalised information about how to support individuals...personal care was not covered in their care plan”
minorStaff training: “The registered manager told us they did not use the Care Certificate as part of their staff induction process.”
Strengths
· Appropriate safeguarding procedures in place; staff demonstrated clear understanding of reporting responsibilities
· Robust staff recruitment practices including DBS checks, employment references and proof of identification
· Medicines managed safely with monthly audits and accurate administration record charts
· Staff understood infection control procedures including handwashing and use of protective clothing
· Lessons learnt from accidents and incidents; effective steps taken to prevent recurrence
Quality-Statement breakdown (18)
safe: SafeguardingGood
safe: Risk assessmentGood
safe: Staffing and recruitmentGood
safe: Medicines managementGood
safe: Infection controlGood
safe: Incident learningGood
effective: Needs assessment prior to careRequires improvement
effective: Staff training and supervisionGood
effective: Nutrition and hydrationGood
effective: Healthcare access and multi-agency workingGood
effective: Mental Capacity Act complianceGood
caring: Dignity, privacy and respectGood
caring: Promotion of independenceGood
responsive: Person-centred care plansRequires improvement
Outreach Support Services Limited was rated Good across all five key questions at its January 2019 inspection, having successfully remediated breaches of Regulation 9 identified at the previous inspection relating to needs assessments and personalised care planning. The service demonstrated safe staffing, consistent care delivery, respectful and culturally competent practice, and effective quality monitoring under a well-regarded registered manager.
Concerns (2)
moderateCare planning: “At the previous inspection in January 2018, we found they were in breach of Regulation 9 because care plans were not personalised and did not include information about how to support people with their personal care needs.”
minorRecord keeping: “The registered manager told us they checked completed medicine charts but made no record of this. We discussed this with them and they said they would implement a system to record that they had checked.”
Strengths
· Previous regulatory breaches regarding needs assessments and care planning had been fully addressed by the time of this inspection
· Consistent allocation of regular staff to people, supporting relationship-building and continuity of care
· Robust staff recruitment procedures including DBS checks, employment references, and right-to-work verification
· Electronic monitoring system in place to ensure staff punctuality and full visit duration compliance
· Staff received regular one-to-one supervision and access to both induction and ongoing training