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Bideford Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 14 June 2019

We rated EDP – Bideford hub as requires improvement overall because:

  • Staff were not always managing risk to clients. Clients who had been using the service prior to April 2018 did not have a disengagement plan in place. A disengagement plan details what the client expects from staff when they disengage from the service or do not attend appointments, for example by contacting their next of kin. This meant that if a client disengaged with the service staff might not know who to contact including relatives, carers or health professionals and others involved in the clients care to make them aware this had happened. Three out of six records reviewed did not contain a risk management plan. Risk management plans did not refer to crisis planning.
  • Staff were not always developing detailed recovery plans which included client’s goals and what treatment they were receiving. At the time of the inspection, the provider had not started the newly developed local care planning audit.
  • Staff did not ensure that clients received a comprehensive assessment of physical health needs from the client's GP or other relevant health professional. Staff were not including client’s physical health needs when developing recovery plans. The provider did not have a physical health monitoring policy and staff were concerned that physical health monitoring was not comprehensive. Only clients who were prescribed medication by the service or undergoing home detoxification had their physical health checked.
  • Staff were not carrying out or referring clients for blood borne virus (BBV) testing. Clients should have been offered BBV testing on-site or referred to their local GP for testing but 0% of clients had been tested referred in the 12 months prior to this inspection.
  • In the Barnstaple clinic, staff were not adhering to infection control principles when testing urine samples. The urine testing facilities were not being used appropriately by staff. When the clinic room was in use, staff were testing urine samples in the kitchen. Staff were disposing of used sample pots in the clinical waste bin in the clinic room without emptying the contents fully. The dedicated toilet for urine testing did not contain a clinical waste bin or an area to test urine samples.
  • The provider did not have a robust recruitment process to ensure all staff had an up-to-date Disclosure and Barring Service (DBS) certificate in place. The human resources (HR) department was responsible for ensuring staff had a valid DBS certificate and had not realised when a number of staff DBS certificates had expired. Managers did not have oversight of this process.
  • Staff were not recording informal complaints. This meant that managers could not be assured that complaints were actioned fully, and complaints could not be analysed to determine themes or trends.
  • Some needles used for the needle exchange service were out of date in the Bideford clinic.

However:

  • The clinical assessment service staff assessed risk at the point of assessment. When clients were allocated a recovery navigator, they would then complete a comprehensive assessment. The comprehensive assessment included completing a risk assessment and incorporated information received from the client’s GP at the point of referral. Clients requiring a prescription received a face to face assessment with the service’s doctors or non-medical prescribing nurses.
  • The clinical assessment service were completing initial assessments with clients within two weeks of receiving a referral. Urgent client referrals were seen promptly. High risk clients were prioritised, for example pregnant women and opiate-users. Staff monitored clients on the waiting list to detect increase in level of risk or need.
  • Staff treated clients with compassion and kindness. They understood the individual needs of clients and supported clients to understand and manage their care, treatment or condition.
  • Staff felt respected, supported and valued by management. Staff and clients described a change in culture in the last six months and felt optimistic and positive about the future direction of the organisation. Managers had introduced initiatives to improve morale such as arranging team away days.
Inspection areas

Safe

Requires improvement

Updated 14 June 2019

We rated safe as requires improvement because:

  • Staff were not always managing risk to clients. The clinical assessment service (CAS) were completing initial disengagement plans for all newly referred clients, however staff were not routinely updating or developing plans with current clients. This meant that if a client disengaged with the service staff might not know who to contact including relatives, carers or health professionals and others involved in the clients care to make them aware this had happened.

  • Clients did not always have a detailed risk management plan in place and did not include reference to crisis planning. Client’s risks were identified but ways to mitigate the risk were not always included. Only three out of six records reviewed contained a risk management plan.

  • Staff were not ensuring that all clients were having their physical health checked regularly. The provider did not have a physical health monitoring policy and staff were concerned that physical health monitoring was not comprehensive. Only clients who were prescribed medication by the service or undergoing home detoxification had their physical health checked.

  • Out of 39 staff, ten did not have an active Disclosure and Barring Service (DBS) certificate. This included staff based at Bideford and the Mid & East Devon team. Four out of 11 clinical staff did not have an active DBS certificate. This is because they were out of date.

  • In the Barnstaple clinic, staff were not adhering to infection control principles when testing urine samples. The urine testing facilities were not being used appropriately by staff. Staff were transporting urine samples from the toilet and testing the sample on the kitchen counter. Staff were discarding used sample pots in the waste bin the clinic room but not emptying them fully, causing the room to smell of urine. The dedicated toilet for urine testing did not contain a clinical waste bin or an area to test urine samples.

  • Some needles used for the needle exchange service were out of date in the Bideford clinic.

However:

  • The clinical assessment service staff assessed risk at the point of assessment. When clients were allocated a recovery navigator, they would then complete a comprehensive assessment. The comprehensive assessment included completing a risk assessment and incorporated information received from the client’s GP at the point of referral. Clients requiring a prescription received a face to face assessment with the service’s doctors or non-medical prescribing nurses.

  • Staff had policies, procedures and training related to medication and medicines management including prescribing, detoxification, assessing people’s tolerance to medication and take-home medication such as naloxone.

  • Staff understood local authority safeguarding processes. Staff worked effectively within teams, across services and with other agencies to promote safety including systems and practices in information sharing. The service had a safeguarding lead and staff could contact them for advice and guidance.

  • Serious incidents were investigated, and any lessons learned shared with staff. Staff were offered debriefs following incidents and we were provided details of changes to practice following investigation of incidents.

Effective

Requires improvement

Updated 14 June 2019

We rated effective as requires improvement because:

  • Staff did not always develop recovery plans that met clients’ needs identified during assessment. Three out of five care records did not contain recovery plans. Recovery plans that had been developed contained client’s identified needs but did not contain details on how clients would meet their goals or what treatment they were receiving.

  • The service did not complete comprehensive assessments of physical health needs and concerns. Staff did not develop recovery plans in response to known or identified physical health concerns. Prescribing staff relied on GP assessment of physical health but the service did not have a comprehensive process in place to ensure this was taking place and physical health needs were being met.

  • In the 12 months prior to the inspection 0% of clients had been offered or referred for blood borne virus (BBV) testing. Staff were trained to complete blood borne virus testing but had not offered testing to clients. Clients should have been referred to their local GP for BBV testing but 0% of clients had been referred in the 12 months prior to this inspection.

However:

  • Clients undergoing an alcohol home detoxification were receiving adequate physical health monitoring.

  • All staff received regular supervision and were supported to further develop their skills through personal development plans. Volunteers and peer mentors were recruited, trained and supported by a manager.

  • Staff provided a range of treatment and care for clients based on national guidance and best practice. Staff used nationally recognised tools to monitor withdrawal symptoms for clients undergoing detoxification.

Caring

Good

Updated 14 June 2019

We rated caring as good because:

  • Staff treated clients with compassion and kindness. They understood the individual needs of clients and supported clients to understand and manage their care, treatment or condition.

  • Staff adhered to and understood clear confidentiality policies and maintained the confidentiality of information about clients.

  • Staff directed clients to other services when appropriate and, if required, supported them to access those services.

Responsive

Good

Updated 14 June 2019

We rated responsive as good because:

  • Clients could access services easily. Referral criteria did not exclude people who would have benefitted from care.

  • The service employed a hospital liaison worker who worked with clients who presented at the local hospital. They supported and encouraged them to engage with the service and liaised with other relevant agencies, such as police and mental health teams.

  • The assessment team completed initial assessments with clients within two weeks of receiving a referral. Urgent client referrals were seen promptly. High risk clients were prioritised for example pregnant women and clients who misused opiates. Staff monitored clients on the waiting list to detect increase in level of risk or need.

  • Staff demonstrated an understanding of the potential issues facing vulnerable groups such as those experiencing domestic abuse or sex workers.

However:

  • Staff were not recording informal, verbal complaints raised by clients. This meant that managers could not be assured that complaints were actioned fully, and complaints could not be analysed to determine themes or trends. 

Well-led

Requires improvement

Updated 14 June 2019

We rated well-led as requirements improvement because:

  • The provider had some gaps in the governance process. The provider’s risk register did not include staff not offering blood borne virus testing or that clients had not been referred to their local GP for testing. Managers had not ensured that staff were completing or reviewing disengagement plans for all clients. Managers had not ensured that staff were completing risk management plans for all clients or that recovery plans were developed that met clients’ needs identified during assessment. Managers had not embedded a local care planning audit.

  • The provider did not have a robust process to ensure staff had an up-to-date Disclosure and Barring Service (DBS) certificate in place. The human resources (HR) department was responsible for ensuring staff had a valid DBS certificate and had not realised when a number of staff DBS certificates had expired. Managers did not have oversight of this process.

  • The provider was in the process of updating their clinical policies. For example, the prescribing ‘Did Not Attend’ (DNA) policy was still in draft form. The provider was in the process of updating all policies due to the recent change in contract. Some staff were unaware that there were updated clinical policies.

However:

  • Staff felt respected, supported and valued by management. Staff and clients described a change in culture in the last six months and felt optimistic and positive about the future direction of the organisation.

  • Leaders had the skills, knowledge and expertise to perform their roles. The registered manager had a good understanding of the service they managed and could explain how the team were working to provide high quality care.

  • Leaders were visible in the service and approachable for staff. Staff knew by name who the clinical leads, service manager and CEO were and how to contact them directly.

Checks on specific services

Community-based substance misuse services

Requires improvement

Updated 14 June 2019

               

EDP – Bideford hub is a substance misuse service providing support to clients in the community.