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Compass - Lewisham Health and Wellbeing Service Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 14 November 2018

We rated Compass – Lewisham Health and Wellbeing Service as requires improvement because:

  • There had been a number of managers for the service, some of whom were managing the service for a short period. Staff reported that they had not felt supported by all managers and there had been inconsistency. There had been a high turnover of staff.

  • There was no record of the learning from incidents being discussed and shared with staff in the service. The provider’s incident matrix guided staff on when to report incidents. Identification and reporting of safeguarding issues and breaches of confidential information were not always reported as incidents. The incident matrix did not ensure that all events and incidents which should be reported as an incident were. The provider did not formally notify the Care Quality Commission of some incidents which it was legally required to.

  • The governance system was not fully effective and did not integrate the provider’s policies with the operational safety, quality and performance of the service. Managers did not have all the information they required. There was no accessible system to have oversight of the quality, safety and performance of the service.

  • The service did not have a system for collating the feedback from young people, families or carers, to identify any themes or trends. This meant an important source of information that could drive improvement was missing.

  • When people made complaints about the service, these were not always recorded or responded to as complaints. Senior managers did not have detailed information concerning complaints. The complaints policy did not contain an appeals process for complainants dissatisfied with a complaint investigation or outcome.

  • Patient group directions for registered nurses to dispense medicines did not include the names of registered nurses authorised to do so. They did not follow legal or best practice requirements. The provider changed these immediately and confirmed no medicines had been dispensed.

  • Information for young people was not always in an accessible format. There were no age appropriate or easy read versions of important information for young people with learning disabilities or reading difficulties.

  • Staff did not measure and record the room temperatures where non-refrigerated medicines were stored. The effectiveness of non-refrigerated medicines may be affected if stored above the maximum temperature of 25 degrees.

  • Staff lone working procedures were not known by all staff and had not been consistently followed.

  • Staff and some managers did not have a full understanding of the duty of candour.

  • Staff did not have a good understanding of the Mental Capacity Act 2005.

However, we also found the following areas of good practice:

  • All young people in the service had a comprehensive assessment and risk assessment. These were detailed, included all aspects of young people’s lives, and included all potential risks. Young people’s wishes and preferences were explicit in their care plan and their risk management plans.

  • Staff provided a range of interventions to support young people’s sexual health, emotional and substance misuse issues. The interventions provided by staff followed best practice guidance from the Department of Health and the National Institute for Health and Care Excellence.

  • Staff displayed understanding, sensitivity and respect when talking about young people using the service. They provided practical and emotional support and ensured that young people were involved in, and directed, the level and type of support they needed.

  • Staff were knowledgeable regarding potential risks to young people, including sexual abuse, gang involvement, child sexual exploitation and neglect.

  • Staff undertook all mandatory training required. The mandatory training rate was 100%.

  • Staff accompanied young people to other services for their first appointment when they required more support. This was particularly important when young people were attending adult services for the first time.

Inspection areas

Safe

Requires improvement

Updated 14 November 2018

We rated safe as requires improvement because:

  • There was no record of the learning from incidents being discussed and shared with staff in the service.

  • Patient group directions, for registered nurses to dispense medicines without a prescription, did not contain a list of registered nurses authorised to dispense medicines. This meant they did not follow legal requirements or best practice guidance. The service changed these immediately and confirmed no medicines had been dispensed since the service had opened.

  • Staff did not measure and record the room temperatures where non-refrigerated medicines were stored. The effectiveness of non-refrigerated medicines may be affected if stored above the maximum temperature of 25 degrees.

  • The procedures for lone working were not clear to all staff and had not been consistently followed.

  • Staff and some managers did not have a full understanding of the duty of candour. They could not recall that when a mistake had been made they had to write to relevant persons to apologise. They did not describe keeping relevant persons updated on how such mistakes would be prevented in future. The registered manager informed us that the criteria for the duty of candour had not been met.

However, we also found:

  • All young people in the service had comprehensive risk assessments. Young people’s risk management plans were based on their risk assessments and focussed on minimising potential risks.

  • Staff were required to complete safeguarding training as part of their induction. We were informed by the manager that this included PREVENT to raise awareness of young people’s vulnerability to radicalisation

  • Staff were knowledgeable regarding potential risks to young people, including sexual abuse, gang involvement, child sexual exploitation and neglect. Members of the team attended multiagency meetings, such as the critical risk safety panel and the missing, exploited and trafficked (MET) meeting.

  • Staff undertook all mandatory training required. The mandatory training rate was 100%.

Effective

Good

Updated 14 November 2018

We rated effective as good because:

  • Staff provided a range of interventions to support young people’s sexual health, emotional and substance misuse issues. The interventions provided by staff in these areas followed best practice guidance from the Department of Health and the National Institute for Health and Care Excellence.

  • Staff completed a comprehensive assessment of young people who had been referred to the service. This assessment was detailed and incorporated their details of their personal, social and family life.

  • Staff had undertaken a wide range of training so they could provide appropriate interventions for young people. Staff had been trained in psychological intervention techniques and had received training regarding sexual health and misuse of prescribed medicines.

  • Staff had a good understanding of how to assess young peoples’ competency. They understood Gillick competency and the Fraser guidelines.

However, we also found:

  • Staff did not have a good understanding of the Mental Capacity Act 2005.

Caring

Good

Updated 14 November 2018

We rated caring as good because:

  • Staff displayed understanding, sensitivity and respect when talking about young people using the service. They provided practical and emotional support to young people, and there were a number of cards from young people thanking the staff for the support they had provided.

  • Staff accompanied young people to other services for their first appointment when they required more support. This was particularly important when young people were attending adult services for the first time.

  • Young people’s wishes and preferences were explicit in their care plan. Staff ensured that young people were involved in, and directed, the level and type of support they needed. Staff also involved families and carers when young people did not have legal competency or when young people consented to their involvement.

  • Young people’s risk management plans were individual and personalised and reflected their preferences and goals.

Responsive

Requires improvement

Updated 14 November 2018

We rated responsive as requires improvement because:

  • The service recorded that one complaint had been received. Minutes of a team meeting recorded that complaints had been received regarding the late cancellation of appointments. These was no record that these were recorded as formal complaints. This meant that senior managers did not have detailed information concerning complaints.

  • The complaints policy did not contain an appeals process for complainants dissatisfied with a complaint investigation or outcome.

  • Information for young people was not always in an accessible format. There were no age appropriate versions or easy read versions of important information for young people with learning disabilities or reading difficulties.

However, we also found:

  • The service had clear care pathways with other local services, particularly the child and adolescent mental health team and youth offending services.

  • Staff understood the specific needs of young people with autism and physical disabilities and young people who identified as gay, lesbian or bisexual.

  • Young people had a choice of where they could meet staff. This could be at the service offices, youth clubs, or at other services. School attenders could access the service at youth clubs in the evenings.

Well-led

Requires improvement

Updated 14 November 2018

We rated well led as requires improvement because:

  • There had been a number of managers for the service, some of whom were managing the service for a short period. Staff reported that they had not felt supported by all managers and there had been inconsistency. There had been a high turnover of staff.

  • The provider’s incident matrix guided staff on when to report incidents. Identification and reporting of safeguarding issues and breaches of confidential information were not always reported as incidents. Use of the providers incident matrix did not ensure that all events and incidents which should be reported as an incident were, or that the provider could monitor these effectively.

  • The service had not made any statutory notifications concerning abuse or alleged abuse of young people to the Care Quality Commission. This was a legal requirement.

  • The managers and team leader in the service did not always have all the information required to operate the service effectively. In addition to incomplete or incorrect performance data, information regarding the service was recorded in a number of different documents. Not all of these were available to managers all of the time. Accurate performance data for four months in 2018 had been collected at the time of the inspection. Information regarding the service was not collected in a way that enabled oversight of key indicators affecting the quality, safety and performance of the service. This included the absence of a system to regularly collect feedback from young people and their parents, to drive improvement.

However, we also found:

  • Staff from the service attended local community events to promote the service and to raise awareness of the service. This work was also undertaken in schools. There were plans to expand the service to more youth clubs.

  • Staff explained and provided information to young people regarding confidentiality and information sharing. If young people could not understand, this was explained to their parents or carers.

Checks on specific services

Substance misuse services

Requires improvement

Updated 14 November 2018