You are here

Archived: Calderdale Recovery Steps - St. Johns House Good

This service is now registered at a different address - see new profile

Inspection Summary


Overall summary & rating

Good

Updated 18 March 2019

We rated Calderdale Recovery Steps as good because:

  • The safety of the service, including that of clients, staff and the environment, was managed well. Incidents were reported, reviewed and learning shared within the service and across the partnership.
  • Staff understood their roles and responsibilities in safeguarding adults and children at risk and carried these out.
  • The multi-disciplinary team provided assessment, care and treatment to clients in line with best practice and national guidelines. Staff were skilled and knowledgeable in their roles and had opportunities for further development. The service monitored closely their performance and outcomes for clients were in line with the national average. The provider had retained accreditation for investors in volunteers.
  • Staff were caring and professional. Feedback from clients and carers was positive, particularly in relation to the range of interventions available and the impact this had on peoples lives.
  • The service took a proactive approach to understanding the needs of different groups of people and delivered care in a way that met these needs and promoted equality. Access to the service was timely and staff were committed to maximising client attendance and commitment to their recovery journey, through a flexible and non-punitive approach. The service ensured clients and carers could make a complaint and was responsive to feedback. The provider retained its Equality Gold Standard award in 2018.
  • The service was well led. Managers were skilled, knowledgeable and experienced. The culture within the service ensured staff felt respected, valued and supported by leaders. Staff morale was high. The service had effective systems and processes in assessing, monitoring and improving the quality and safety of the service. Managers had identified areas for improvement and had plans in place to address these. Leaders supported the development of staff and fostered a culture of continuous improvement and innovation. Managers at all levels understood the challenges within the service and the treatment population and were driven to achieve better outcomes.

However:

  • The service did not assess the capacity of a client in a timely way when concerns were identified in relation to capacity to consent to treatment.
  • Cleaning records were not completed, and the infection control and fire audits did not demonstrate that the actions had been completed.
  • Care records did not always clearly reflect individual recovery goals or the extent of client involvement into the development of care plans.
Inspection areas

Safe

Good

Updated 18 March 2019

We rated safe as good because:

  • The service assessed and managed client risk appropriately. Clients had up to date risk assessments and risk management plans, which included plans for unexpected exits from treatment.

  • The service had robust incident reporting and management systems. Staff received feedback following incidents and learning was embedded within the organisation and across the partnership.

  • Staff were knowledgeable on how to safeguard adults and children and made the appropriate referrals to the local authority.

  • The service had sufficient staff and compliance with mandatory training was high.

  • Both locations were clean, tidy and well maintained. Clinic rooms had essential equipment and this was checked regularly.

However:

  • Risk management plans were brief and contained generic statements. Two risk management plans were not comprehensive and did not explain fully how the identified risk would be managed.

  • Cleaning records were not completed, and the infection control and fire audits did not demonstrate that the actions had been completed.

Effective

Good

Updated 18 March 2019

We rated effective as good because:

  • All clients received a comprehensive assessment of their needs and had a care plan that met their needs.

  • Staff provided a range of care and treatment interventions in line with best practice and national guidance.

  • The service engaged in a range of audit activities to improve the quality of care and treatment for clients. Treatment outcomes were monitored closely to measure effectiveness locally and against the national picture.

  • Staff were skilled and experienced in substance misuse and had opportunities to develop their skills and knowledge.

  • The service had a multi-disciplinary team of staff who could deliver a range of interventions.

  • The provider retained the Investors in Volunteers accreditation award in 2018.

However:

  • The service did not assess the capacity of a client in a timely way, when concerns were raised in relation to their capacity to consent to treatment.

  • Care records did not always include detailed recovery plans with clearly identified goals.

Caring

Good

Updated 18 March 2019

We rated caring as good because:

  • Staff provided treatment with a sense of optimism and positivity. Staff provided responsive, practical and emotional support to clients and those close to them.

  • The service offered a range of interventions to maintain and improve clients’ social networks, employment and education opportunities.

  • The service involved clients, families and carers in the running of the service, actively seeking feedback to improve the service.

  • Clients provided positive feedback about the service and the impact it had on their lives.

However:

  • Care records did not always clearly reflect the extent of client involvement into the development of care plans.

Responsive

Good

Updated 18 March 2019

We rated responsive as good because:

  • The service provided timely access for clients for triage and assessment.

  • The service ensured clients remained engaged with their care and treatment plan, through a flexible and non-punitive approach. Staff were proactive in supporting clients who unexpectedly dropped out of treatment.

  • The service was responsive to the needs of all groups of people using the service.

  • The service supported clients to engage with the wider community to access employment and education opportunities and to achieve stability and build recovery capital.

  • The service ensured clients and those close to them could make a complaint. Clients told us they were confident to make a compliant. The service monitored and reviewed complaints to identify any themes or trends that indicated the service needed to make improvements.

  • In November 2018 Humankind successfully maintained the Equality Gold Standard Award, in recognition of planning and promoting good equality and diversity practices in the workplace.

However:

The environments in Halifax and Todmorden were tired and in need of updating.

Well-led

Good

Updated 18 March 2019

We rated well-led as good because:

  • The service had a strong and established leadership team with the skills, knowledge and experience to perform their roles.

  • Staff were valued, respected and supported by leaders. Staff were proud to work for Humankind.

  • Systems and processes were effective in assessing, monitoring and improving the quality and safety of the service. Clinical audit was proactive and productive within the service.

  • The service had an established framework of meetings to ensure essential information, such as risk and performance, was shared across the organisation and within partnership.

  • There was commitment towards continual improvement and innovation. The provider had retained awards for equality and investors in volunteers.

  • Both staff and clients had opportunities to give feedback about the service.

However:

  • The service should continue with its plans to improve the environment within the service and embed the ongoing work in relation to care records.

Checks on specific services

Substance misuse services

Good

Updated 18 March 2019