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East Kent Substance Misuse Service - Swale Good

Inspection Summary


Overall summary & rating

Good

Updated 20 June 2019

We rated East Kent Substance Misuse Swale good overall because

  • The service provided person centred care that clearly focussed on individual needs. There was a great commitment towards continual improvement and innovation. A specialist hepatitis nurse attended the service to reduce stigma and barriers to treatment. Data provided by the service showed that 15 clients had been referred for treatment since November 2015. A peer mentor supported clients attend their appointments to encourage engagement in treatment for hepatitis C. There was an alcohol pathway to support clients with alcohol issues. The service was in the process of developing a dedicated pathway for clients who used opiates and for trauma informed care.
  • The service actively sought to reduce stigma and engage hard to reach and treatment naïve clients. Staff, including the clinical team, offered flexible appointments and times and saw clients in a range of settings, including at home, to reduce barriers to treatment and meet individual need. Staff supported clients with additional needs including benefits and housing. There was a daily drop in service so that people could access the service without an appointment for advice and information. The service offered a weekly evening clinic to accommodate clients who were employed or preferred to be seen outside of normal working hours. The service provided an out of hours telephone line. A member of staff carried toiletries in their car to give to clients who were homeless or in need.
  • There were targeted surveys and the service invited feedback from clients throughout their treatment. There were feedback forms and a suggestion box in the waiting room to capture suggestions to improve and develop the service.
  • The clinic room was clean, tidy and well equipped. There was an emergency grab bag that contained emergency medicines. The needle exchange was well stocked and harm reduction advice was displayed and available for clients to take with them. Staff stored medicines securely and there were robust systems in place for the management of prescriptions.
  • There was a range of disciplines in each team which included specialist doctors, non-medical prescribers, recovery workers with a range of qualifications and peer mentors with lived experience. The clinical team had extensive knowledge and skills of working within substance misuse. All staff completed an induction which included mandatory and core training. There was specific management and leadership training for managers. Staff had lead roles including safeguarding and dual diagnosis that staff could go to for advice and support.
  • Safeguarding was clearly embedded in all aspects of the service. There was a safeguarding and domestic abuse lead at the service that provided advice and bespoke training for staff.
  • Managing risk was integral to the service. Staff completed risk assessments and risk management plans that were reviewed regularly. Risk was discussed during appointments. Staff were able to track and monitor risk levels on the electronic client record. Staff completed recognised screening tools and withdrawal tools to assess dependence and to monitor and respond to risk. The service provided lockable boxes to clients prescribed detoxification medicines, to reduce risk of inappropriate ingestion. Staff provided and trained clients, families, carers and relevant professionals how to administer naloxone to reduce the risk of opiate related deaths.
  • The assessments and interventions provided by the service were line with National Institute of Health and Care Excellence guidelines. The provider offered a specific alcohol pathway for clients which explored the physical, mental and social effects of alcohol misuse. The service used innovative ways to provide harm reduction advice to clients including via drug alert text messages about possible adulterated drugs which could prove fatal if used.
  • Staff demonstrated a genuine interest in clients’ wellbeing. Staff spoke about clients with compassion, dignity and respect. Staff were non-judgemental and strived to ensure that clients’ needs were all met. A carers lead had recently started a carers and support group.
  • There was a clear management structure for the service. Leaders had the skills, knowledge and experience to perform their roles. Team leaders had a good understanding of the service and clearly explain how to provide high quality care.
  • Staff said they were supported and valued by managers and colleagues and felt able to raise concerns without fear of victimisation. The service promoted equality and diversity and provided opportunities for apprentices, volunteers and peer mentors with lived experience of substance misuse.
  • The service had clear quality assurance management and performance frameworks in place. There were clear frameworks of what needed to be discussed at service level to ensure that essential information, such as learning from incidents, was shared and discussed. The communications team sent a weekly e-bulletin to staff.
  • Managers and clinicians completed a variety of audits to ensure a safe, effective and responsive service. Managers and staff had oversight of dashboards to monitor caseload, risk, recovery plans and clients’ care and treatment.

However:

  • We reviewed five recovery plans which were basic and did not focus on client strengths. Staff told us that recovery plans were completed collaboratively with clients, but none of the recovery plans we reviewed contained a client’s signature. Staff did not routinely offer clients a copy of their recovery plan.
  • Clients’ routine medical reviews were sometimes delayed because the doctor and non-medical prescriber were shared across the two teams because another doctor employed by the service had recently retired.
  • Despite staff explaining risks of leaving treatment early to clients, only one of the five care records reviewed included a plan for unexpected exit from treatment.
  • Care record audits only involved checking the electronic dashboards of staff and did not consider the quality of the information. Staff didn’t track the client records that had been audited.
  • The business continuity plan and some of the service’ risk assessments were out of date.
Inspection areas

Safe

Good

Updated 20 June 2019

We rated safe as good because:

  • The clinic room was clean, tidy and well equipped. There was an emergency grab bag that contained emergency medicines. There was a well-stocked needle exchange and harm reduction advice was displayed and available for clients to take with them. Staff stored medicines securely and there were robust systems in place for the management of prescriptions.

  • Staff were skilled, competent and experienced. They demonstrated a high level of understanding about the physical and mental health effects of substance misuse. The clinical team had extensive knowledge and skills of working within substance misuse. Caseloads had been adjusted for team leaders to account for additional responsibilities because of reduction from two to one team leader per team.

  • Staff followed the service’s prescribing and treatment policy for clients receiving medically assisted treatment which was in line with national guidance. Doctors completed a comprehensive medical assessment before prescribing detoxification medicines.Doctors and non-medical prescribers monitored clients daily for the first five days of their treatment and were competent in recognising signs of deterioration of physical or mental health.

  • Safeguarding was clearly embedded in all aspects of the service. Staff discussed safeguarding as a regular agenda item at meetings and there were robust systems in place to respond to concerns. There was a safeguarding and domestic abuse lead at the service that provided advice and bespoke training for staff. The safeguarding lead maintained a safeguarding register which recorded details of all clients who had social services involvement.

  • Staff completed risk assessments and risk management plans that were reviewed regularly. The doctor discussed risk during medical appointments. Staff were able to track and monitor risk levels on the electronic client record. Staff completed recognised screening tools and withdrawal tools to assess dependence and to monitor and respond to risk.

  • The service provided lockable boxes to clients prescribed detoxification medicines, to reduce risk of inappropriate ingestion. Staff provided and trained clients, families, carers and relevant professionals how to administer naloxone to reduce the risk of opiate related deaths.

However:

  • Only one of the five records reviewed contained a plan for unexpected exit from treatment. However, risks including leaving the service before the treatment was complete was discussed with clients during their ongoing appointments.

  • Although the doctor and non-medical prescriber offered regular clinics, they were shared across the two teams. This meant that routine appointments were affected by urgent referrals or prison releases, although clients were offered alternative appointments.

Effective

Good

Updated 20 June 2019

We rated effective as good because:

  • There was an innovative treatment pathway for clients at risk of contracting hepatitis C. A specialist hepatitis nurse attended the service to reduce stigma and barriers to treatment. A peer mentor supported clients attend their appointments to encourage engagement in treatment for hepatitis C.

  • There were dedicated treatment pathways to ensure client needs were met. The service was in the process of developing a dedicated pathway for clients who used opiates and for trauma informed care.

  • The service used innovative ways to provide harm reduction advice to clients including via drug alert text messages about possible adulterated drugs which could prove fatal if used.

  • Comprehensive and medical assessments were thorough and holistic. Assessments were in line with National Institute of Health and Care Excellence (NICE) guidelines QS11. Staff arranged appropriate interventions including electro cardiograms for clients who were prescribed high doses of detoxification medicines. The service offered a wide range of interventions in line with NICE Guidelines QS23. The provider offered a specific alcohol pathway for clients which explored the physical, mental and social effects of alcohol misuse.

  • There were a range of multidisciplinary meetings so that staff could share information and discuss complex clients. Staff worked closely with a range of professionals to ensure that the needs of the clients were met. The service had recently introduced prescriber forum meetings to share good practice and monitor clinical targets.

  • All staff completed an induction which included mandatory and core training. There was specific management and leadership training for managers.

However:

  • We reviewed five recovery plans which were basic and did not focus on client strengths.

Caring

Good

Updated 20 June 2019

We rated caring as good because:

  • Staff demonstrated a genuine interest in clients’ wellbeing. Staff spoke about clients with compassion, dignity and respect. Staff were non-judgemental and strived to ensure that clients’ needs were all met.

  • Feedback from clients was mostly positive. Clients said that they had a good relationship with their recovery workers. They said that staff were non-judgemental and that they were happy with their care and treatment. One client told us of the opportunities they had been given regarding peer mentorship at the service. One of the seven clients we spoke with said they felt let down because they felt their support had stopped when they had completed their treatment. Feedback about the satellite service was mainly positive.

  • There were targeted surveys for clients and the service invited feedback about client experience of their treatment to improve and develop the service. Families and carers could access the drop-in service for advice and support.

  • There was a carers’ lead who had recently started a carers group. Staff involved families and carers in clients’ treatment, where client consent had been obtained. We observed a carer attending a medical assessment for a client who was about to start an alcohol detox, so that they could ask questions and manage expectations. A carer told us that staff were supportive and involved them in their relative’s care, ensuring that confidentiality was maintained.

However:

  • Staff told us that recovery plans were completed collaboratively with clients, but none of the recovery plans we reviewed contained a clients’ signature. Staff did not routinely offer clients’ a copy of their recovery plan.

Responsive

Outstanding

Updated 20 June 2019

We rated responsive as outstanding because:

  • The service actively sought to reduce stigma and engage hard to reach and treatment naïve clients by providing treatment from a range of satellite services and conducting home visits. The service offered incentives including food vouchers, to encourage clients to be vaccinated against blood borne viruses.

  • There was a daily drop in service so that people could access the service for advice and information without an appointment. The service offered a weekly evening clinic to accommodate clients who were employed or preferred to be seen outside of normal working hours. Clients could use an out of hours telephone number to speak with staff if required.

  • Staff, including the clinical team, offered flexible appointment times and saw clients in a range of settings, including at home, to reduce barriers to treatment and meet individual need. Staff saw clients in a number of satellite services so that clients did not need to travel long distances to be seen.

  • Staff appropriately signposted clients for specialist support where required. A member of staff carried toiletries in their car to give to clients who were homeless or in need.

  • Staff saw clients within 24 hours of allocation and completed a comprehensive assessment within seven days.

  • The service offered a range of interventions dependent upon need. Clients who required clinical input engaged in structured treatment. Clients who needed more unstructured treatment were offered focussed brief intervention appointments.

  • We observed staff supporting clients throughout their treatment and transfer between services including hospitals. There was a dedicated member of staff to ensure the smooth transition of clients care who had been released from prison.

  • The provider had recently merged with an employment specialist that supported clients to access education, training and employment and enhance integration into the community.

  • The service invited feedback from clients throughout their treatment. There were feedback forms and a suggestion box in the waiting room to capture feedback to improve and develop the service.

Well-led

Good

Updated 20 June 2019

We rated well-led as good because:

  • There was a clear management structure for the service. Leaders had the skills, knowledge and experience to perform their roles. Team leaders had a good understanding of the service and clearly explain how to provide high quality care.

  • Staff and team objectives were based on the provider’s vision and values. Staff understood the vision and values of the service and their role in achieving them. Staff had lead roles including safeguarding and dual diagnosis that staff could go to for advice and support. Staff contributed to the development of the service and had made changes to better meet the needs of clients.

  • Staff said they were supported and valued by managers and colleagues and felt able to raise concerns without fear of victimisation. The service promoted equality and diversity and provided opportunities for apprentices, volunteers and peer mentors with lived experience of substance misuse.

  • The service had clear quality assurance management and performance frameworks in place. There were clear frameworks of what needed to be discussed at service level to ensure that essential information, such as learning from incidents, was shared and discussed. The communications team sent a weekly e-bulletin to staff.

  • There was a clear audit trail and risk management for prescription management.The service had a dedicated prescription team to process repeat and instalment prescriptions. Prescribers cross referenced people’s care records to ensure any changes to prescribed medicines were updated before authorising prescriptions.

  • Managers and clinicians completed a variety of audits to ensure a safe, effective and responsive service. Managers and staff had oversight of dashboards to monitor caseload, risk, recovery plans and clients’ care and treatment.

  • The service had a business continuity plan to ensure that services would be maintained for clients in the event of emergencies. For example, in the event of adverse weather.

  • The service completed regular surveys with clients. Staff invited feedback from clients at various stages of their treatment and via the comments box in the waiting area.

  • There was a commitment towards continual improvement and innovation. There was an alcohol pathway to support clients with alcohol issues. A specialist hepatitis nurse provided treatment for hepatitis C from the service. The service was in the process of developing a dedicated pathway for clients who used opiates and for trauma informed care.

  • Staff had worked hard to identify satellite services that would be most appropriate for clients in terms of location and stigma. Staff worked hard to reduce the barriers for clients accessing treatment.

However

  • The business continuity plan and some of the service risk assessments were out of date.

  • Care record audits only involved checking the electronic dashboards of staff and did not consider the quality of the information. No record was kept of client records that had been audited, meaning that there was no way of knowing which records had been reviewed.

Checks on specific services

Substance misuse services

Updated 25 January 2018

Community-based substance misuse services

Good

Updated 20 June 2019


Substance misuse services

Good

Updated 20 June 2019