We are With You - Rotherham

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

All staff knew what incidents to report and how to report them, they had a good understanding of the processes and what followed once they reported something. Staff reported all incidents that they should report.

Staff understood the duty of candour. They were open and transparent and gave clients and families a full explanation if and when things went wrong.

Staff received feedback from investigation of incidents, both internal and external to the service. There were well structured teams in place and because the majority worked in one building, it was clear that communication between teams was effective.

Staff met to discuss that feedback. We saw evidence of regular team meetings which were well attended and well documented. Minutes from these meetings showed that there was an effective mechanism for learning to be shared. There was also the opportunity for complex cases to be discussed at regular multi-disciplinary team meetings, which staff could book time-slots for if they needed to.

There was evidence that changes had been made as a result of feedback. For example, following a number of incidents that occurred as a result of people waiting for long periods in the building, learning identified new practices which were able to speed up the processing of prescriptions to ensure people were waiting for less time.

Staff told us that they were debriefed and received support after incidents.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. People could use an online system to self-refer and this information was quickly reviewed so that people could be seen as soon as possible. Staff worked well together to ensure that people received a timely assessment to enable them to access treatment as soon as they could.

Staff involved all the necessary health and social care services to ensure people had continuity of safe care, both within the service and post-discharge. This included people that were being admitted and discharged from hospital and those that were able to be transferred into shared care, which meant they could be seen at a doctor’s surgery in their community. This also includes people that were moving between the community and the criminal justice system, for example being released from prison back into the local area.

The service gathered and analysed data in relation to referral, discharge and waiting times to help them understand the flow of clients in and out of the service, to ensure that resources were used effectively.

All staff were trained in safeguarding, knew how to make a safeguarding alert, and did this when appropriate. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Because of the nature of the work, it was common for staff to work in a multi-agency approach to manage risks effectively. This included adults and children effected by domestic violence and at risk of exploitation.

Staff followed safe procedures for children visiting the service.

We did not observe any blanket restrictions being used.

We looked at 6 risk assessments and risk management plans during the assessment.

Although some care plans and risk management plans lacked detail, it was clear from the whole care record that staff involved patients in care planning and risk assessment. Staff had made comprehensive notes following each appointment and these included conversations and plans about risk management and goals. Risks were being managed effectively.

When we visited the service, staff were implementing a new care plan for each person using the service, this would make it easier for clients to engage in the process and take away a copy of their care plan. The management team were able to share a detailed implementation plan for this new piece of work.

Staff communicated with clients in a way that helped them understood their care and treatment, including finding effective ways to communicate with clients with communication difficulties or language barriers.

Staff enabled clients to give feedback on the service they received, this took place via online surveys and in specific face to face sessions. Although take up of the online survey was limited, staff had managed to gain valuable feedback from people about what types of activities might help them in their recovery journey.

Staff ensured that patients could access advocacy.

Staff carried out regular risk assessments of the environment to ensure that maintenance and safety were at a high standard. There were potential ligature anchor points, but staff had mitigated the risks adequately. Clients were risk assessed and those that might be a higher risk were not left alone in rooms and where possible used rooms on the ground floor.

Staff had easy access to alarms and staff told us that the team were responsive if the alarms were ever used. There were designated responders allocated each day to ensure that a suitable number of staff acted if it were needed.

Clinic rooms were fully equipped with accessible emergency equipment and emergency drugs that staff checked regularly.

The service made sure there were enough qualified, skilled and experienced people to meet the needs of the clients. There were a small number of vacancies which meant that some caseloads were higher than the service wanted them to be, but staff said they were able to manage the workload. There was no evidence of unsafe practice because of short staffing.

Turnover over the last 12 months was 26% but the rates at which people were leaving more recently was falling. The service used a small amount of agency staff, but again, more recently this was decreasing. Agency staff that were used were suitably trained and experienced and had undertaken a routine induction into the service.

Managers had calculated the number prescribers required to meet the needs of the service. This meant that there was adequate medical cover to ensure that prescriptions could be administered safely and effectively and that where necessary, medical assessments could be carried out by suitably qualified staff, sometimes at short notice or urgently.

Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the client group using the service.

Staff were receiving supervision on a regular basis. Staff told us that they were well supported by their line managers and by the wider management team that had taken over within the last year.

Staff maintained equipment well and kept it clean. All areas were clean, had good furnishings and were well-maintained.

Cleaning records were up to date and demonstrated that the building was cleaned regularly.

Staff adhered to infection control principles, including hand-washing.

Staff followed good practice in medicines management and did this in line with national guidance. This included the safe storage and administration of naloxone, which is an emergency antidote for overdoses caused by opiates. Staff also had effective systems in place to safely distribute injecting equipment and paraphernalia and to dispose of any returns that were brought back to the service for an exchange.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with National Institute for Health and Care Excellence guidance.