Archived: On-Trak (Kirklees Alcohol Service)

We do not currently rate independent standalone substance misuse services.

We found the following areas of good practice:

• The service had responded to the areas of concern identified in the previous inspection. We found that the service had improved systems and processes related to the management of staff. A new system had been introduced to monitor compliance with mandatory training. Staff files showed that staff consistently received an annual appraisal and regular supervision. The service had updated checks with the disclosure and barring service for all staff. The service had undertaken a specific check of all staff member’s ‘right to work’ documentation.
• The service had introduced a risk register and had taken action in response to issues highlighted during the previous inspection related to environmental risks.
• Staff awareness of the duty of candour had improved since the last inspection and all staff were able to provide a detailed description of the duty of candour and scenarios where it would apply. The service had introduced an electronic register to record incidents and there was evidence that notifiable incidents were consistently reported to the Care Quality Commission.

However, we found the following issues that the service provider needs to improve:

• Client records showed that there was inconsistent quality in the documentation which supported the service’s approach to assessing and managing clients’ risks.
• Whilst all of the actions identified in the previous inspection that the provider must take to improve had completed, the actions identified that the provider should take to improve had not been completed. The service had not introduced an annual audit cycle and the whistleblowing policy and equality and diversity policy was still overdue for review.
• There were issues with the electronic database used to record dates for annual appraisal which meant that compliance data was unreliable.

We do not currently rate independent standalone substance misuse services.

We found the following issues that the service provider needs to improve:

• Some staff had not received training in adult safeguarding, child safeguarding, or managing challenging behaviour. Only 60% of staff had received an appraisal in the 12 months prior to our inspection.
• There were no systems in place to monitor mandatory training, appraisals or supervision. The service did not have an annual audit cycle. The service did not have a local risk register.
• The whistleblowing policy and equality and diversity policy was overdue for review.
• The service failed to report notifiable incidents to the Care Quality Commission.
• Not all staff had up to date disclosure and barring checks.

However, we found the following areas of good practice:

• Staff were aware of local safeguarding procedures and understood their responsibilities in safeguarding children and adults. Staff were knowledgeable about the risks around alcohol withdrawal and provided harm minimisation advice to clients, advising them how to reduce their alcohol intake safely.
• The service had sufficient staff and had not used bank or agency staff in the last 12 months prior to the inspection.
• All clients received a thorough initial assessment and staff documented this accordingly. The service’s revised recovery action plans took a holistic approach to care planning and promoted staff to consider the clients recovery capital. The service was offering interventions underpinned by national guidance.
• Staff worked had good working relationships with external organisations and worked closely alongside them to support the clients.
• The service had morning and evening handover meetings so staff could identify pieces of work that needed covering and highlight areas of concern.
• We observed kind and compassionate care delivered to people who use the service. The people who used the service were very complementary about the effectiveness of staff, and the quality of the care. There was a system in place for clients to feedback about the service.
• Local stakeholders such as citizens advice and housing services attended drop in clinics to support clients with other issues impacting on their lives.
• Clients who were abstinent from alcohol and had completed the recovery programmes could work as peer mentors by supporting new clients attending the service. They also facilitated group work with staff.
• Clients were provided with an assessment at a time that suited them. Staff were able to arrange the first one to one appointment after the assessment within a week. Clients had access to groups and activities whilst waiting for their one to one appointments to begin.
• All the rooms were appropriate for use and optimised client comfort.
• The service was culturally diverse and staff went out of their way to engage with hard to reach clients which included people who were homeless. The service had employed a specialist diversity worker.
• Staff were motivated in their roles and had good morale. There was a strong team ethic, and staff felt well supported by local management. Sickness levels were very low with an average of 2% in the last 12 months.