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East Kent Substance Misuse Service - Swale Good

Reports


Inspection carried out on 9 April 2019

During a routine inspection

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 carried out on 7 November 2017

During a routine inspection

We do not currently rate independent standalone substance misuse services.

We found the following areas of good practice:

  • Staff undertook a detailed assessment of the needs of each client before they started using the service. Staff carried out a comprehensive assessment of risk for each client and ensured information about risk issues was communicated well with others.

  • The service had robust safeguarding systems in place to ensure staff responded promptly to any concerns. Staff discussed details of vulnerable clients on the safeguarding register during regular meetings. There was a safeguarding lead at the service that staff could speak to for advice.

  • Staff stored medicines securely and there were safe, robust systems in place for the management of prescriptions. The Service had a well-stocked needle exchange in line with National Institute for Health and Care Excellence guidelines (NICE52) needle and syringe programme.

  • The service had a mix of healthcare professionals who were all highly skilled and competent. Staff operated safe prescribing practice. The prescribers were knowledgeable and able to assess and prescribe for alcohol and drug detoxification

  • The provider had established the staffing levels required through consultation with the service commissioners and worked closely with them to ensure staffing and caseload management remained safe.

  • Doctors completed a comprehensive assessment for all new clients and completed regular medical reviews for clients receiving a medically assisted treatment. We observed a medical review, which was structured and comprehensive. The service contacted a client’s GP prior to and after prescribing any medication.

  • Care plans contained comprehensive and holistic information. They addressed the client’s various needs, in accordance with the client’s individual preferences and goals. Staff involved clients in their treatment throughout their recovery and treatment pathway. Staff met regularly to review clients’ cases and discuss complex cases and actions plans

  • A wide variety of psychosocial interventions was available to support clients’ recovery.

  • The service offered residential or inpatient detoxification for opiate and alcohol dependent clients who they considered a higher risk.

  • Staff offered testing and vaccinations for hepatitis A and B. They also offered screening for hepatitis C and human immunodeficiency virus (HIV).

  • Staff had good working relationships with other agencies including GP’s, pharmacists, the community mental health team, young person’s drug and alcohol service and supported housing providers, to provide comprehensive and holistic care for clients.

  • Staff were knowledgeable and experienced for their role. The service had identified staff who acted as ‘champions’ in various roles including safeguarding and multi-agency risk assessment conference (MARAC).

  • The service had a good volunteer, apprentice and peer mentor programme which provided former clients the opportunity to gain new skills and support new clients in their recovery.

  • We obtained feedback from 14 comments cards from the service. Client’s spoke highly about the care and compassion they received from staff. They spoke of the support they received and said staff were non-judgemental, friendly, courteous and considerate. Staff were compassionate and keen to maintain clients’ privacy and dignity.

  • Managers and staff sought feedback and views from clients using the service. Clients had opportunities to give feedback via comment boxes, during key worker sessions or via the peer mentors.

  •  The service offered a drop-in session every afternoon so that staff could see people without an appointment. The service offered a late clinic one evening a week to reduce barriers to accessing treatment and staff could see employed clients outside of normal working hours. There was a single point of access telephone number for clients to use outside of normal working hours.

  • Needle exchange provision was available including people who were not engaged in structured treatment. Staff provided harm reduction and safer injecting advice to people accessing this service.
  • The service undertook outreach in the community to help clients who may find it difficult otherwise to access services. The service offered appointments and groups at five satellite services.
  • Where clients did not attend appointments or disengaged from the service, robust systems were in place for staff to follow up with the client and attempt re-engagement.
  • The service had a large range of information available relating to other local services including safeguarding, housing and welfare services and mental health and physical health support.
  • The service had robust governance structure and good assurance and auditing systems in place. The service completed audits to monitor and develop service delivery. The service had a clear complaints policy and procedure. Clients knew how to make a complaint.
  • The service had an operational risk register to identify priority risks and implement an effective plan to mitigate risks. Staff had oversight of dashboards to monitor caseload, risk, care plans and client care and treatment.

  • Staff morale was high, their workload was manageable and they had job satisfaction. Staff told us they felt encouraged and motivated to provide the best service they could. There was a culture of promoting staff within the service and supporting them to achieve.

  • The service had supportive and experienced management and leadership who demonstrated a good knowledge of the model of delivery for the service

  • The provider had worked closely with stakeholders and partner agencies to design their treatment model. The service planned to implement the co-designed model in January 2018. Feedback from the commissioner was that the provider had managed the transition and performance of the service well.

However, we also found the following issues that the service provider needs to improve:

  • Not all staff at the service had completed the mandatory e-learning courses. Data provided by the service showed that three staff had not completed any of the mandatory e-learning training. Four staff had only completed some of the required modules. Six staff had not completed the policy and compliance mandatory training, which included modules on safeguarding adults and safeguarding children. No staff had completed emergency first aid at work or fire warden training.

  • The risk register did not include timeframes for actions to be completed.

  • Managers did not have immediate access to Disclosure and Barring Service (DBS) check information for volunteers and peer mentors.

  • The provider had completed an analysis of staff training needs. However, they had not acted on the information provided. This meant that the service had not acted on gaps in training for staff.

  • The provider did not offer Mental Capacity Act training for staff. Staff knowledge of the Mental Capacity Act was limited. However, staff could explain how to respond if a client attended under the influence of drugs or alcohol.

  • Although the service displayed advocacy posters, staff knowledge of support available was limited.

  • Data provided by the service showed that six of 15 staff had not completed all of the mandatory training.

  • The service was embedding relevant policies. However, the prescribing and treatment policy did not reference the updated drug misuse and clinical management guidelines.