I Straker Consultants Ltd

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• 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

We rated safe as inadequate. We assessed 8 quality statements. Staff were not always suitably qualified or trained to complete assessments and medical reviews. There was no process to assure their competency in these roles. The service did not ensure staff followed policy to ensure that relevant service user history was sought from their regular prescribers to ensure controlled drugs could be safely prescribed. The service did not have a robust process for the management of prescription stationary. However, the environment was clean and well maintained. Staff had completed safeguarding training and processes were in place to raise safeguarding concerns.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Service users that we spoke with and received feedback from did not raise any concerns regarding incident management. Service users we spoke with had not been involved in a serious incident or an incident that had required further feedback. None of the service users we spoke with had raised a formal complaint.

Staff we spoke with told us they would inform management of any issues or incidents that occurred. Staff were able to describe who they would report different incident types to. For example, any incidents related to health and safety or acts of aggression were reported to the service manager. Clinical incidents were reported to the lead prescriber. Staff told us that incidents were reported either by email or when required verbally and that there was not a specific form to complete. Incidents were discussed in dally meetings. Managers we spoke with told us that incidents were also discussed in the weekly and monthly management team meeting which were minuted and shared with staff. Staff we spoke with told us that there were not many incidents that required reporting.

The provider told us that there was an electronic incident reporting system and tracker in place. However, the staff we spoke with did not reference this in interviews and told us they reported incidents either by email or verbally. Staff we spoke with were not aware of an incident tracker. The service did have a log of complaints that had been received which included the outcome and agreed resolution where appropriate. There was a complaints policy in place. Staff sought to resolve complaints informally before the formal complaints policy was invoked. There was a copy of the service’s complaints policy available on the service’s website. Discussions around reported incidents and complaints were held with staff in the daily meeting, this included feedback on any findings or agreed actions. There was space for managers to discuss incidents and complaints in a weekly management meeting.

Service users we spoke with and received feedback from did not raise any concerns in relation to safe systems, pathways and transitions. Service users had either self-referred into the service or been referred by a medical professional. We did not speak to any service users who had been transferred to shared care. However, we spoke to service users who were undergoing medicine optimisation at the service who told us that they had been provided with information around the shared care process and how and when they would be transferred.

Staff told us that the service had systems and pathways in place to work with GPs. Managers told us that there was a process in place to request information from a service user’s GP before commencing prescribing. They told us that prescribing should not begin until that information had been received. However, some staff we spoke with told us that information was not always sought, or received prior to patients’ being prescribed. Our review of records confirmed this.

Staff we spoke with were able to describe the process for referring service users’ to shared care once they had been titrated and stabilised on medication. They understood at what point in the treatment process referral should begin and were able to discuss the options available to service users where shared care either wasn’t an option or had been declined by the GP.

We did not receive feedback from partners.

There was a process in place to request patient information from GPs prior to commencing treatment. However, we reviewed five records and found that only one record had a full patient summary in place. In the other records there was either no evidence of a request for information or prescribing had been started without the information being received. There was a shared care protocol in place to support staff. The service maintained a shared care log to detail which patients had been referred and which patients had their prescribing transferred to their GP under shared care arrangements. The service had a certificate of diagnosis document that was sent to GPs as part of the transfer of care.

Service users we spoke with and received feedback from did not have any specific safeguarding concerns and were not involved in active safeguarding processes.

Staff we spoke with confirmed they had completed safeguarding training as part of their induction and ongoing mandatory training requirements. They demonstrated a good understanding of safeguarding issues and were able to describe different types of abuse and what constituted a safeguarding concern. Staff knew who to contact for advice within the service and understood the process to raise a safeguarding concern internally and to the local authority.

We did not review any assessments where a safeguarding concern had been identified or actioned. We did not identify the need for a safeguarding in those records. We observed a daily staff meeting and saw that safeguarding was considered as part of the standard agenda. However, there were no new safeguarding concerns to review as part of the meeting.

Staff completed safeguarding training as part of their mandatory training programme. Staff completed separate courses covering the safeguarding of adults and the safeguarding of children. At the time of our assessment compliance with both safeguarding training courses was 100%. There was a safeguarding policy in place. The registered manager was the identified designated safeguarding officer for the service. Safeguarding and safeguarding concerns were a standard agenda item on the daily staff meeting.

We received feedback from three service users during our assessment. Feedback on their involvement in risk management and the quality of risk management was mixed. One service user we received feedback from told us they felt their risks were managed. However, one service user told us they did not feel their risks were managed and that they did not feel safe. We did not receive feedback on risk management from the third service user.

Feedback we received from staff during our assessment process in relation to the management of risk was mixed. Staff told us that they did consider potential risks when completing assessments and conducting medical reviews. We observed staff asking questions around areas such as self harm and suicidality during assessments. However, not all staff we spoke with felt they were suitably trained or experienced to be able to identify or understand the possible risks inherent in the patient group and diagnosis. This was particularly relevant when working with children and young people. Staff told us they could take any concerns they did have to managers or for discussion in the weekly assessment review with the specialist psychiatrist. Staff also told us they could raise any concerns they had over patients or patient risk and the daily staff meeting. This included any safeguarding concerns.

We were not assured that risks were always identified or managed. We were not assured that staff completing assessments were fully trained to do so, especially in relation to children and young people. We reviewed 5 assessments and found that in each assessment no specific risks had been identified. In one assessment we reviewed the patient stated that they drank occasionally and sometimes to excess on their own. Although copies of assessments were shared with patients and included a paragraph stating not to drink whilst on stimulant medication this was not captured as a potential risk during the assessment and there was no evidence it had been discussed with the patient.

The service had clinical guidelines that detailed the standard medicine titration pathway. The service did not have a qualified prescriber onsite every day and prescribers pre-signed prescriptions for clients based on the standard titration pathway. Medical reviews were completed by Mental health therapists. However, they had not received appropriate training to help them identify possible concerns or risks. In addition, a guide to support the Mental health therapists had not been embedded. This meant there was a risk of inappropriate prescribing and an increased risk of adverse side effects.

Systems and processes that might identify potential risks were not always robust or always followed. For example, we reviewed 5 records and found only one had a GP summary in place prior to prescribing commencing. This was not in line with the provider’s policy. In addition, we found that not all prescribing staff had access to relevant information on the care record system. For example, not all prescribers had access to the file hosting server where GP summaries and certificates of diagnosis were kept. Communications between staff and external healthcare professionals were kept in individual staff’s email inboxes and not easily accessible to other staff in the event of absence or leave.

Service users we spoke with and received feedback from did not raise any concerns regarding the environment. They told us the environment was clean and welcoming.

Staff we spoke with did not raise any concerns regarding the environment and equipment available to them. Managers told us that rooms had been painted different colours as some individuals with ADHD or autism prefer specific colours. They gave us an example of one patient who always used one specific room due to the colour of the walls. Managers told us that lamps had been put into interview rooms so these could be used if patients found the lighting too bright. Staff did not carry personal alarms but confirmed they would see a patient with a colleague if they had any concerns.

The service was located on the ground floor of a managed building which had fully accessible services such as toiles. There was a reception and waiting area with tea and coffee making facilities. There was information available for service users on the service, treatment and relevant mental and physical health conditions. There were sufficient rooms to meet need. There was one room identified as family friendly which included some toys and child appropriate activities. We found that rooms were not fully soundproofed. However, staff were aware of this and ensured they did work from adjoining rooms whilst completing assessments or patient medical reviews.

The service was located within a building with a dedicated building manager. The building manager oversaw annual health and safety and fire safety assessments. The building manager conducted regular checks of fire detection and firefighting systems as well as completing fire evacuation drills. The service manager completed a daily walk around of the environment and escalated any concerns to the building manager.

We received feedback from three service users during our assessment. Feedback about staff was generally positive and service users felt staff were caring and compassionate. However, one service user we received feedback from told us they found they could not always get a response from the service and could not always speak to someone about their concerns.

Feedback we received from staff during our assessment process in relation to safe and effective staffing was mixed. Staff generally felt there were sufficient staff to meet need. However, some staff told us that they did not feel appropriately trained or qualified to carry out their roles and responsibilities. Some staff told us that they had not been fully aware of what their role would entail until they took up the position, and that they weren’t given sufficient support to confidently deliver functions such as assessment and medical reviews. Staff told us they had access to reglar supervision. This included monthly 1 to 1 supervision and bi-monthly group supervision.

Staff did not always have the experience or training to carry out their duties. Although formal diagnosis of service users was made by a consultant specialist, they only attended the site on one day a week and did not routinely see service users themselves. Service user diagnoses were made based on a review of assessments completed by assistant psychologists. However, the assistant psychologists had not received specific training on the assessment of neurodiversity and autism, especially in relation to children and young people. The service did not complete competency assessments for this role to help assure the quality and safety of the assessment process. Medication reviews, including decisions on dose titration were completed by mental health therapists. There was a policy to guide the therapists, but they had received no specific clinical training to help them complete the reviews and identify potential risks or concerns. The service did not complete competency assessments for the role to help ensure the quality and safety of the reviews. A guide to support mental health therapists in the role had not been embedded. Following our inspection, the provider told us they would deliver training on the completion of medication reviews to Mental Health Therapists.The service relied on specialist input from the consultant psychiatrist as there was no other specialist health care professionals. However, the consultant did not review patients directly and was only available on site 1 day a week. As a result, we were not assured that specialist oversight of prescribing and monitoring of patients' medicines was safe. We reviewed recruitment practices and found that staff had provided references and completed Disclousre and barring services checks before commencing employment. These included checks to ensure suitability to work with children and young people.

Staff completed a programme of mandatory training which included first aid, safeguarding, infection control, GPDR and the handling of aggressive behaviour. However, staff had not received specialist training relevant to their role. For example, mental health therapists had not received training around completing medical reviews. Staff received an induction to the service when they started their role. This included an orientation to the building and staff. As part of their induction new staff were buddied up with an existing member of staff for support.

Service users we spoke with and received feedback from did not raise any concerns regarding infection control. They told us that the building and service was clean and well maintained.

Staff we spoke with told us the premises were cleaned regularly, and they had no concerns regarding infection prevention and control. Staff had access to anti-bacterial wipes to clean down equipment and toys in the family room after use.

We reviewed the environment as part of our assessment. All areas were kept clean and were well-maintained. Staff had access to infection prevention and control resources including anti-bacterial wipes, hand gel and cleaning materials. We observed staff following infection control principles including using handwash.

There were no formal infection control audits. The service manager completed daily walk throughs of the environment and escalated any concerns to the building manager. The building manager maintained cleaning records for the premises. The service had a standard operating procedure covering infection control.

We received feedback from three service users during our assessment. We received feedback mixed feedback in relation to medicines optimisation. One service user expressed specific concerns in relation to medicines management and told us that prescriptions had been incorrectly written, for example containing the wrong dose or an inaccurate number of tablets that had impacted the patient and the ability of pharmacists to dispense

During the assessment period staff we spoke with told us they did always feel supported or appropriately qualified to complete their roles. Mental health therapists who carried out medication reviews told us they did not receive training around the medicines they were reviewing. Prescribers would prescribe based on the outcome of these reviews. Whilst we did not see any instances of inappropriate prescribing on the day of the assessment, there was a risk that not all concerns would be appropriately identified and raised to the relevant specialist for review.

Service leaders did not monitor the competency of the mental health therapists to make decisions about people’s medication. The service introduced a guide to further support MHTs conducting these reviews. However this had not yet been embedded.

The registered manager of the service told us that information from patients’ GPs should be sought before the service initiated prescribing. However, we did not find that this was always the case. In a sample of five records we reviewed we found that only one record demonstrated liaison with the patients GP and the receipt of a full patient summary

We did not observe instances of care.

We could not be assured that medicines were being prescribed appropriately. Medicines for ADHD must be initiated and overseen by a specialist. However, the specialist in the service worked only one day a week. Qualified prescribers were not always onsite and medical reviews were completed by staff who did not have adequate training or experience to carry out the role. We reviewed 5 records and found only 1 had a GP summary in place before prescribing had commenced. This was against national prescribing guidance and the provider’s policy. As a result, we were not assured that prescribing decisions were being made with the relevant medical history. For example, the service was not routinely asking female patients if they were pregnant or were attempting to get pregnant. The service was reliant on patients’ self-disclosing any other medication they were prescribed that might be contraindicatory with ADHD medication.

Staff did not always follow the service’s policy when maintaining notes on patient care. Notes did not always contain full details of what was discussed at patient reviews. Patient records were not kept in line with national guidance. Patient notes were not indelible. This meant that records could be amended at a later date. The system used by the service did not record what had been amended.

The service did not have safe processes and procedures to manage and monitor controlled drug prescription forms. We identified concerns around practice and processes in relation to prescription forms due for destruction which left them liable to misuse. Prescription that were not in use were not securely stored. The service did not have a process to identify if prescriptions were missing. The service could not provide assurance that at the time of inspection no prescriptions were missing.

Relevant consent to treatment was not always recorded in patients records. We did not see records of consent when medicines were being used outside their license.