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CHART Kirklees Requires improvement

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 21 January 2019

We rated CHART Kirklees as requires improvement because:

  • Staff had not completed comprehensive up to date risk assessments with each client. Where risks were identified it was not clear how staff planned to manage risks effectively. Clients did not have crisis plans in place and we did not see evidence in care records that clients were receiving physical health assessments in-line with the service’s policies. 
  • Staff had not completed a comprehensive and holistic assessment and treatment plan with each client. Staff had not consistently recorded goals related to what clients wanted to achieve through engagement with the service. Staff had not recorded discharge plans or plans for unexpected exit from treatment. Staff recording of client information was inconsistent, with staff recording information in different locations within the electronic client record system.

However:

  • Feedback from clients about staff and the service offered was consistently positive. Clients were satisfied with the frequency of their appointments and were supported by staff to understand their care and treatment. Clients could attend a variety of groups and appointments were made at flexible times to suit the needs of the clients. Clients were provided with access to appropriate supporting services and families and carers were supported and involved in client care where appropriate. Clients knew how to give feedback and make complaints about the service, and the service was responsive to feedback given. 
  • There were sufficient numbers of suitably skilled staff who were up to date with required mandatory training. Clients had input into their assessment and care from a multidisciplinary team, all of whom could attend regular team meetings. Staff knew how to report incidents, including safeguarding alerts. Testing and vaccination against blood borne viruses were routinely offered to clients.
  • Managers were visible throughout the service and staff told us that managers were approachable. Staff told us they felt respected and valued and were passionate about their role. There was a clear framework and agenda of what must be discussed within meetings at both team and directorate level to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.
Inspection areas

Safe

Requires improvement

Updated 21 January 2019

We rated safe as requires improvement because:

  • Staff had not completed comprehensive up to date risk assessments, risk management plans or crisis plans with each client.
  • Staff recording of client information on the electronic records system was inconsistent with staff recording information in different locations.
  • We did not see evidence in care records of clients receiving a physical health assessment or a review in-line with service policies.

However:

  • The service’s buildings and facilities were clean and well-maintained and staff adhered to infection control principles. Staff carried out regular fire drills and testing of fire equipment and the service carried out regular environmental and fire risk assessments.
  • There were sufficient numbers of trained staff to meet the needs of the service users. 
  • Staff knew how to report incidents, including safeguarding alerts, and discussed incidents during daily meetings.

Effective

Requires improvement

Updated 21 January 2019

We rated effective as requires improvement because:

  • Staff had not completed a comprehensive and holistic assessment with each client, taking account of health, personal care, emotional, social, cultural, religious and spiritual needs.

  • Staff had not consistently recorded goals related to what the client wanted to achieve during their treatment.

  • Records did not include a discharge plan or plan for unexpected exit from treatment and there was no evidence of clients being offered a copy of their care plan.

However:

  • Staff provided a range of care and treatment interventions suitable for the client group. The interventions were those recommended by, and were delivered in line with, guidance from the National Institute for Health and Care Excellence.

  • Testing and vaccination against blood borne viruses were routinely offered to clients, and nurses and health care assistants were trained in dry blood spot testing.

  • Clients had multidisciplinary input into their assessment and care; staff from all disciplines could attend daily team meetings. 

  • The service had effective protocols in place for clients utilising shared care.

Caring

Good

Updated 21 January 2019

We rated caring as good because:

  • All clients had a named recovery co-ordinator who acted as a point of contact for the service.

  • All of the clients we spoke with were happy with the frequency of their appointments and the level of support they were receiving.

  • Staff treated clients in a caring and compassionate way. We observed positive interactions between clients and staff during the inspection and received consistently positive feedback from clients about the way that staff treated them. 

  • Clients and those close to them were provided with access to appropriate supporting services.

  • Staff supported clients to understand their care and treatment and would provide additional support around this when required, for example use of visual aids and videos and access to interpreters.

Responsive

Good

Updated 21 January 2019

We rated responsive as good because:

  • The service had clear admissions criteria and could see clients urgently where required.

  • The service offered flexible appointment times and outreach visits to meet the needs of clients. Staff utilised various methods to re-engage clients who disengaged from the service. 

  • The service, in collaboration with its’ partnership organisations, offered a wide variety of group activities to encourage clients to develop and maintain relationships with others, as well as supporting clients wishing to engage in education or employment. 

  • Information relating to how to make a complaint was available in both service buildings. Complaints were reviewed and acted upon in line with the service’s policy.

However:

  • Staff had not documented discussions with clients around discharge planning or early exit from treatment.

  • Two of the rooms on the third floor at the Dewsbury site were not adequately soundproofed as voices could be heard through the adjoining wall.

Well-led

Good

Updated 21 January 2019

We rated well-led as good because:

  • Leaders within the service had the skills, knowledge and experience to perform their roles, and staff told us leaders were visible and approachable. Staff told us they felt respected and valued by their colleagues and managers. 

  • Managers had identified problems and created action plans where improvement was required within the service.

  • Staff knew about the whistleblowing process and how to use it if required. Staff told us they could raise concerns without fear of retribution.

  • There was a clear framework and agenda of what must be discussed within meetings at both team and directorate level to ensure that essential information was shared and discussed.

  • The service encouraged innovation to ensure clients were supported to engage.

However:

  • Systems and procedures put in place to manage the implementation of the new electronic recording system had not been effective in ensuring care records were complete, including up to date risk assessments and care plans, and sufficient client data and information had been migrated.

  • Not all staff were aware of how escalate risks to be submitted to the provider’s risk register.

Checks on specific services

Substance misuse services

Requires improvement

Updated 21 January 2019