You are here

CGL Norfolk Alcohol and Drug Behavioural Change Service Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 12 September 2019

We rated CGL Norfolk as requires improvement overall because:

  • Information relating to the safety of clients was not always comprehensive or timely. During the inspection we found risk assessments for clients that were out of date and not reviewed following an incident. Not all records contained GP summaries and there was a lack of crisis plans throughout. Care plans lacked detail. Overarching recovery goals were not routinely documented and did not reflect discussions held with the client. There was a lack of discharge planning and clients’ plans did not always address the potential risks of early exit from the programme.
  • The service did not keep a safeguarding log. Therefore, managers were not able to review outcomes and did not have oversight of reporting.
  • Staff compliance with basic life support skills was 19%.
  • Staff had not received an annual appraisal of their work performance.
  • We found some incidents reported had passed the timeframe for review by managers of the service.

  • The provider did not always have governance systems in place to effectively manage the service. Governance policies, procedures and protocols were regularly reviewed and improved to ensure the service delivered safe, good quality interventions in line with national best practice. however, these were not fully embedded.

However:

  • The service had robust health and safety systems in place to manage the safety of the environment. All areas at the services were clean and well maintained. Clinic rooms, testing rooms and needle exchanges were well stocked and were kept locked when not in use.

  • Staff held daily flash meetings where all staff engaged in detailed discussion of client risks. Where appropriate these risks were shared with relevant stakeholders. Staff worked effectively within teams, across services and with other agencies to promote safety including systems and practices in information sharing.

  • Staff completed an initial assessment for clients in a timely manner and the care plan identified the person's recovery worker. The service ensured multidisciplinary input into people's initial assessments and staff provided a range of care and treatment interventions suitable for the client group.

  • Staff were open and welcoming to all who attended. Clients were able to drop in to the service and staff would see them. Staff would offer responsive and emotional support. Staff talked about clients with compassion and respect.
  • Clients we spoke with told us that staff were always available and they received positive support. Clients felt safe and said that staff were caring and welcoming. Staff enabled families and carers to give feedback on the service they received.
  • The service was able to see clients who were urgently referred quickly. There was a system in place to ensure priority cases were given the earliest appointment available. Those people discharged from hospital were also made a priority and seen quickly. The service had alternative care pathways and referral systems in place for people whose needs could not be met by the service.
  • Staff demonstrated an understanding of the potential issues facing vulnerable groups. Staff at the service promoted equality and diversity, this included lesbian gay bisexual transgender+ and black and minority ethnic groups. Staff were passionate in this area and were involved in events in the local community to support this.
  • Leaders at the service had the skills, knowledge and experience to perform their roles, and provided leadership to their staff.  The organisation had a clear definition of recovery and this was understood by all staff. Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing.
Inspection areas

Safe

Requires improvement

Updated 12 September 2019

We rated safe as requires improvement because:

  • We found 10 out of 26 risk assessments were out of date and four risk assessments viewed were not updated following an incident. Only five of those records contained GP summaries and there was a lack of crisis/relapse plans throughout. Care plans did not always address the potential risks to people of early exit from the programme.

  • The service did not keep a safeguarding log. Therefore, managers did not review outcomes and there was no oversight of reporting.

  • The completion rate for basic life support training for staff was 19%.

However:

  • The service had robust health and safety systems in place to manage the safety of the environment. The provider had completed a basic ligature risk assessment in all four hubs and had put control measures in place to mitigate risk. Fire risk assessments and evacuation tests were up to date.

  • All areas at the services were clean and well maintained. Clinic rooms, testing rooms and needle exchanges were well stocked and were kept locked when not in use. All hubs we visited had a daily dedicated cleaning contract in place and cleaning schedules were up to date.

  • The service provided detailed and informative harm minimisation advice across all four hubs to clients making them aware of the risks of continued substance misuse.

  • Staff held daily flash meetings. All staff engaged in detailed discussion of client risks. Where appropriate, these risks were shared with relevant stakeholders.

  • Staff worked effectively within teams, across services and with other agencies to promote safety including systems and practices in information sharing.

Effective

Requires improvement

Updated 12 September 2019

We rated effective as requires improvement because:

  • Care plans lacked details; overarching recovery goals were not routinely documented and did not reflect discussions held with the client.

  • The provider did not deliver or participate in smoking cessation schemes.

  • Staff had not received an annual appraisal of their work performance.

However:

  • Staff completed an initial assessment for clients in a timely manner and the recovery plan identified the person's recovery worker. 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.

  • The service ensured multidisciplinary input into people's initial assessments. Nurses and recovery workers co located in local hospitals and had effective protocols in place for the shared care of people who use their services.

  • Staff supported clients to minimise risks associated with substance misuse. The service offered safe storage for the return of needles and offered safe storage boxes for clients to use at home to safely store their medicines.

  • Blood borne virus testing was routinely offered and the provider worked closely with an NHS trust who facilitated hepatitis C clinics.

  • Recovery workers reviewed care plans and used recognised recovery tools such as the Severity of Alcohol Dependence Questionnaire, Alcohol Audit and the Treatment Outcomes Profile.

Caring

Good

Updated 12 September 2019

We rated caring as good because:

  • Staff were open and welcoming to all who attended. clients were able to drop in and someone would see them and offer responsive and practical emotional support. Staff talked about clients with compassion and respect.

  • Clients we spoke with told us that staff were always available and they received positive support. Clients felt safe and said that staff were caring and welcoming.

  • Staff were able to demonstrate they knew their clients well to meet their individual needs and to manage their care, treatment or condition through group work, interventions, self-help and drop in recovery cafes. Staff directed clients to other services when appropriate and, if required, supported them to access those services.

  • Staff enabled families and carers to give feedback on the service they received. For example, surveys, and suggestion boxes were available in all hubs. We saw outcomes of surveys displayed in reception areas.

Responsive

Good

Updated 12 September 2019

We rated responsive as good because:

  • The service had alternative care pathways and referral systems in place for people whose needs could not be met by the service. We saw evidence of alternative treatment options being discussed if a person was not able to comply with specific treatment requirements.

  • The service was able to see those urgently referred quickly. There was a system in place to ensure priority cases were given the earliest appointment available. Those discharged from hospital were also made a priority and seen quickly.

  • Staff demonstrated an understanding of the potential issues facing vulnerable groups. For example, female clients who had experienced domestic abuse, and sex workers, were able to access women-only services.

  • Staff at the service promoted equality and diversity, this included lesbian gay bisexual transgender+ and black and minority ethnic groups. Staff were passionate in this area and were involved in events in the local community to support this.

  • There was a system in place for finding support and treatment for homeless clients who were sleeping rough in the community.

  • The provider’s complaints procedure was well advertised at all hubs and complaint forms were easily accessible. Complaints records demonstrated that individual complaints had been responded to in accordance with the provider’s complaints policy.  We saw evidence that hub managers discussed complaints at team meetings. Staff learned from complaints.

Well-led

Good

Updated 12 September 2019

We rated well-led as good because:

  • Although some elements require improvement, the overall standard of service provided outweighs those concerns. We have deviated from our usual aggregation of key question ratings to rate this service in a way that properly reflects our findings and avoids unfairness.

  • The registered manager of the service had strategic oversight of all four hubs. Locality managers and team leaders at the hubs felt the manager was visible in the service and accessible to clients and staff.

  • Leaders at the service had the skills, knowledge and experience to perform their roles, and provided leadership to their staff. The organisation had a clear definition of recovery and this was understood by all staff. Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing.

  • Staff reported that the provider promoted equality and diversity in its day to day work and in providing opportunities for career progression.

  • All information needed to deliver care was stored securely and available to staff, in an accessible form, when they needed it. Staff had good understanding of confidentiality and clearly explained to clients the process in place for sharing information and data. The service had confidentiality agreements in place which clearly explained this for clients.

  • Clients and carers had the opportunity to give feedback about the service they received. Clients had been present in interview panels for recruiting staff.

However:

  • The provider did not always have governance systems in place to effectively manage the service. Governance policies, procedures and protocols were regularly reviewed and improved to ensure the service delivered safe, good quality interventions in line with national best practice. However, these were not fully embedded.

  • We found some incident reports had passed the timeframe for review by managers.

Checks on specific services

Community-based substance misuse services

Requires improvement

Updated 12 September 2019