The Retreat York

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 means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

Good: This meant people were safe and protected from avoidable harm.

Managers understood their responsibility under duty of candour and had written to apologise where appropriate to clients.

We looked at five records and found they were all up to date with risk reviewed in monthly client progress appointments. We also saw staff reviewing risk when referrals were made to the service.

The service had increased the number of psychiatrists and the number of clinic hours since the last assessment.

Staff followed systems and processes to prescribe medicines safely. The clinic did not hold medication on site and prescriptions were sent to local pharmacies for dispensing, posted to clients or prescriptions were picked up directly from the service.

However, there was still a long waiting time from referral to first assessment with a practitioner. The service had addressed issues from the previous assessment such as ease of contacting the service, increasing staffing levels and improving, ‘did not attend’ statistics.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There had been no serious incidents at the service in the last 12 months. Staff knew what incidents to report and how to report them. Incidents and concerns were a standing item on agendas for staff and management meetings.

Staff felt that they were able to raise concerns about care and treatment if they had any.

Staff we spoke with knew what their responsibilities were under the duty of candour. They could provide examples of when they had provided apologies to clients when things had gone wrong. Managers reported that five incidents had formally met the threshold for the duty of candour in the 12 months prior to the assessment. All these related to emails sent to the wrong person. The importance of accuracy when sending email had been impressed upon staff in team meetings.

Complaints from family members and people who used the service were investigated and resolved with actions put in place where required. There had been four complaints in the last 12 months, mostly about waiting times.

At our last assessment, the waiting times for clients to access an assessment was 18 months and the, 'did not attend' policy and process to expedite clients was not considerate of the challenges faced by this client group. At this assessment, the waiting times were similar, but the service had embedded processes to identify and expediate those assessed as high risk and did not attend appointments were running at 11% of the total appointments. There were also administration staff who managed this process, and they were in contact with those on the waiting list and easily contactable. Clients told us they would have liked an earlier appointment, but we saw staff triaging referrals, speaking to clients on the waiting list and managing that process to ensure it was as efficient as possible.

Once clients successfully completed their treatment and were on a stable medication regime, they were transferred to their GP who maintained their treatment and who could refer clients back to the service if there was a change in circumstances.

Staff were trained in safeguarding vulnerable adults and safeguarding vulnerable children. At the time of the assessment, the training compliance rates were 100%. The service had an identified safeguarding lead who had oversight of all ongoing safeguarding issues, and they were trained to safeguarding level three.

Staff could give clear examples of how to protect people from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to make a safeguarding referral and who to inform if they had concerns.

The registered manager was knowledgeable in the notifications required to external organisations such as the Care Quality Commission.

At our last assessment we found the service did not manage risks to clients or staff in line with organisational policies. Staff did not always use the format specified or had not updated risk assessments in the timeframes stated. On this assessment we looked at five client records and found they were all up to date with risks reviewed in monthly client progress appointments. We also saw staff reviewing risk when referrals were made to the service.

All clients had a full physical health assessment and there was evidence that this was reviewed on an ongoing basis.

There had been four complaints in the last 12 months, and one of those had been upheld. Most complaints were about waiting for an initial assessment.

At the last assessment concerns were raised about the environment, however the service had moved location since that assessment. The new location, The Tuke Centre, is a large building set in its own grounds. It is a 1920’s style house. The service had completed a risk assessment for the building and all the gas, legionnaire and fire safety checks were in place. There were alarm call bells in the interview rooms and the entrance to the service was locked and controlled by reception staff.

There was a clinic room which was used to complete physical health checks such as blood pressure, height and weight. At the last inspection, blood pressure machines and weighing machines had not been calibrated. On this assessment, we found they were in date as were defibrillators. The clinic room was clean.

The clinic room cleaning records were up to date.

At the last assessment the ADHD service had a consultant psychiatrist who worked two afternoons a week and a nurse prescriber who worked four days a week. This provision had been increased to two full time psychiatrists and three administrators.

The service had several staff including the manager, sessional support workers and administrative staff who worked in other services at The Retreat. These staff supported the ADHD service while not directly commissioned to do so.

We saw the administrators managing the appointments for the psychiatrists and they ensured all clinic times were full.

While not directly employed for the ADHD service, three psychologists were available to support clients.

The service was 100% compliant with mandatory training.

All areas were clean, well maintained, well-furnished and fit for purpose. Staff made sure cleaning records were up-to-date, and the premises were clean.

We observed that identified maintenance issues were reported and logged appropriately.

Staff appeared to follow infection control guidelines, including handwashing. Infection prevention and control was referenced within the health and safety policy. This meant that clients were protected from the risk of health acquired infections.

Clients accessed the building by using a buzzer and staff met them at the office entrance to let them in. Clients were then asked to wait in a waiting area. There were appropriate policies in place in relation to health and safety, including fire.

Staff followed systems and processes to prescribe medicines safely. The clinic did not hold medication on site and prescriptions were sent to local pharmacies for dispensing, posted to clients or prescriptions were picked up directly from the service.

Staff reviewed each client’s medicines regularly and provided advice to clients and relatives, if appropriate, about their medicines.

Staff stored prescribing documents safely in a locked safe within the office. Only relevant staff had access to this safe. The service ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines. The service followed National Institute for Health and Care Excellence (NICE) guidelines and medication was not routinely offered as a first-line treatment for Attention Deficit Hyperactivity Disorder (ADHD).

Staff reviewed the effects of each client’s medicines on their physical health according to guidance.