Archived: Brook West Bromwich

We carried out an announced comprehensive inspection on 24 October, 2016 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led.

Our Key findings:

We found that this service provided the following:

• Staff were aware the requirements of being open and honest.
• Staff protected young people from avoidable harm.
• Staff recognised early signs of abuse.
• Clinical staff were provided with support from the clinical manager based at Brook West Bromwich.
• Care and treatment for young people were planned and delivered in line with up-to-date national recommendations and legislation.
• Staff reviewed consent practices and records to ensure young people were involved in making decisions about their care and treatment in line with relevant legislation.
• Staff were committed to working collaboratively with external organisations in order to deliver joined up care for young people.
• Staff completed a Fraser guideline assessment for all young people under 16.
• Staff had access to a regular clinical newsletter with up to date information.
• The privacy, dignity, and confidentiality of young people attending the service was protected and staff treated them respectfully at all times.
• Staff treated young people as individuals and there was a strong visible young person centred culture within the service.
• The feedback from young people who used the service was consistently positive.
• Young people gave clear examples, which demonstrated the value they placed upon the service and how staff supported them.
• The service was planned and delivered in a range of locations and at suitable times, to ensure the service was convenient and accessible to the local population.
• The facilities and premises were suitable for the delivery and effectiveness of the service.
• Young people had access to reception staff by telephone to obtain advice regarding local clinics and to book appointments.
• There was a proactive approach to understanding the needs of young people and to deliver services in a way which supported them and demonstrated equality.
• Brook West Bromwich had vision and values, which were embedded within the service.
• There were a number of policies and procedures accessible to staff on the intranet.
• Managers completed general risk assessments in relation to the service.
• Staff were aware of their responsibilities and were knowledgeable within their role.
• Young peoples' opinions were valued and acted on; there were comment cards available for young people to complete.
• The management team recognised future priorities.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements.

We identified regulations that were not being met and the provider must:

The provider must ensure that all clinical staff who contribute to assessing, planning, and evaluating the needs of a child or young person are trained to safeguarding at level three as recommended in the Safeguarding children and young people: roles and competencies for health care staff’ by the Royal College of Paediatrics and Child Health, March 2014.

The provider must ensure infection control training is completed by all staff providing direct clinical care and involved in specimen collection and transportation.

The provider must ensure there is a local risk register in place to provide overview of local risks.

There were areas where the provider could make improvements and should:

• The provider should ensure that staff are up-to-date with their annual mandatory training and appraisals.
• Ensure that training documentation is consistent, up-to-date and easily accessible to all members of the management team.
• Ensure that all incidents are recorded and their severity assessed when they meet Brook young people’s incident reporting criteria.
• The provider should ensure that all staff have access to training on Mental Capacity Act 2005 and how this applies to young people under 25’s.

We issued the provider with three requirement notice(s) that affected Brook West Bromwich. Details are at the end of the report.