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Archived: South Regional Office Good


Inspection carried out on 18 and 19 September

During a routine inspection

We rated South Regional Office as good because:

  • At the last inspection in May 2017, we told the provider it must make improvements and notify the Care Quality Commission (CQC) of all client’s deaths (as per regulatory requirements). On this inspection the service demonstrated that it had been providing notifications appropriately. The service had regional quality leads who were responsible for ensuring CQC statutory notifications were submitted.

  • Lead nurses conducted monthly clinical site audits to check site cleanliness, safe medicine storage and prescription administration records that were ratified by senior managers. Action plans were then devised and followed up if issues were noted.

  • The service had an appropriate number and mix of staff with relevant knowledge and qualifications to fulfil their role. All staff working at the service, including volunteers, had valid Disclosure and Barring Service checks completed before commencing work.

  • Staff completed comprehensive assessments of every client at their initial appointment and had appropriate admissions criteria in place to support suitable clients. Assessments included substance misuse history, medical history, safeguarding issues, employment and social history. Staff undertook a comprehensive risk assessment of every client at their initial assessment and regularly updated them as necessary. Care and recovery plans were mostly goal orientated, holistic and included client views and wishes.
  • Clients’ physical health conditions were considered as part of initial assessments and regularly reviewed. Blood borne virus testing and vaccination programmes were conducted at all sites.
  • The service utilised a duty system with emergency appointments available and had staff members assigned and available for open access drop-in clients daily.
  • The service had a safeguarding policy in place and staff demonstrated a good awareness of the safeguarding procedure.
  • Staff spoke about clients in a sensitive, caring and professional manner. Clients were very positive about the service they received and said that staff took a genuine interest in their wellbeing.
  • The service had a clear confidentiality policy in place that staff adhered to and explained to clients during the assessment process.
  • The service had an appropriate ‘did not attend’ policy in place and a missed appointment tool that team managers reviewed before any unplanned discharges were made.
  • Staff demonstrated an understanding of the potential issues facing vulnerable client groups and the service employed specialist staff to support these groups.
  • Service leaders had the appropriate skills, knowledge and experience to perform their roles and could explain the role and function of their teams well. All management staff received in-house leadership development training.
  • There was a clear clinical governance structure in place to ensure that clinical risk was escalated and managed within the service. The service held local integrated governance team meetings that fed into an overarching national integrated governance team meeting where service quality improvement plans were also monitored.


  • Overall appraisal rates for all inspected sites were below 65% completion but the service had plans in place to address this.

  • In Gloucester, five of the eight care records reviewed did not include client views and it was not clearly documented if clients received or were offered a copy of their recovery plan.
  • The Southampton site was not accessible to disabled clients. There was no access to the 1st and 2nd floors where groups were held and the emergency cord in the disabled toilet was too short to reach.

Inspection carried out on 08 - 10 May 2017

During an inspection to make sure that the improvements required had been made

We do not currently rate independent standalone substance misuse services.

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

  • The service was not informing Care Quality Commission, without delay, of client deaths in relation to the required statutory notifications. This was in breach of a regulation. Further information is detailed at the end of this report.

  • We found that client risk assessments and management plans were not always updated in the risk assessment documentation. Staff recorded detailed discussions of risk in other sections of the client files.

  • We found some client’s care planning documentation had not been recently reviewed or updated. Recording of detailed care planning was not contained within the services formal care planning documentation.

However, we found the following areas of good practice:

  • Medicines management was robust and efficient across the whole service.

  • The service received a requirement notice under regulation 12 safe care and treatment at the last inspection in relation to disclosure and barring service checks. On this inspection, all staff and volunteers had disclosure and barring service checks in place or pending. The service had good procedures and policies in place regarding these checks.

  • The service received a requirement notice under regulation 15 premises and equipment at the last inspection in relation to a missing hand basin in the Doctors clinic room in Chichester. On this inspection, a hand basin had been installed in the doctor’s clinic room in Chichester to improve infection control procedures.

  • The service had governance structures in place to highlight and address quality issues pertaining to client risk.

Inspection carried out on 31 October to 4 November 2016

During a routine inspection

We do not currently rate independent standalone substance misuse services.

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

  • Not all staff in the service had attended their mandatory training and not all staff at Swindon, Maidstone, Hastings and Eastbourne had received regular supervision.

  • There were a number of staff across all services, except for Worthing, who did not have renewed disclosure and barring service checks in place as per their three yearly renewal policy.

  • A number of risk assessments we reviewed in Maidstone were out of date and one client did not have one.

  • Care plans for clients in Worthing, Chichester, Hastings and Eastbourne were generic and did not include client strengths and steps needed to reach their stated goals.

However, we found the following areas of good practice:

  • Offices and clinic rooms were clean, tidy and well equipped to meet clients’ needs.

  • Services had a range of staff to deliver a variety of interventions in their services and local communities to engage those in treatment and those who services found hard to engage.

  • Once clients proved they were stable on their methadone prescriptions and not using any illegal drugs, staff risk assessed clients' readiness to enable them to collect their prescriptions and self-dose.

  • All services had qualified clinical staff and strong processes in place to monitor clients’ health and offer detoxification programmes depending on client need.

  • There was good involvement of peer mentors and recovery coaches to offer clients support from people who had lived experience of recovery.

  • Staff worked closely with local support services. Staff referred clients to services appropriate to meeting their needs and understood the value of multidisciplinary and inter-agency working.

  • The provider had a clear three step programme to support clients from first engagement (change), to designing their recovery (grow), through to reaching abstinence (live).

  • There were no waiting lists at the services and all referrals were triaged on receipt. This allowed staff to see urgent referrals quickly.