Archived: Brook Tipton

We carried out an announced comprehensive inspection on 26 October 2016 to ask the service the following key questions; Are services safe, effective, caring, responsive and well led.

Our Key findings:

We found that this service provided the following:

• Staff were caring and passionate about their work in supporting young people using the service.
• Staff were responsive and flexible in their approach to helping young people.
• Staff knowledge of the service was good.
• Patients were positive about the service provided.
• Information provided to patients was up-to-date and appropriate to this patient group.

However:

• Mandatory training in safeguarding level 3 was not fully completed for all staff
• Infection, prevention and control (IPC) training on chlamydia testing was not completed annually
• Procedures for learning from incidents and audits were not robust
• Some contingency planning was not evident in case of emergency
• Maintenance schedules and provision for building repair was missing
• Facilities for staff training were not ideal at this site
• General lack of facilities for staff/patients (hot drinks)

We identified regulations that were not being met and the provider must:

• The provider must ensure that all clinical staff who contribute to assessing, planning, and evaluating the needs of a child or young person are trained to safeguarding at level three as recommended in the Safeguarding children and young people: roles and competencies for health care staff’ by the Royal College of Paediatrics and Child Health, March 2014.
• The provider must ensure all staff that provide direct clinical care and involved in specimen collection and transportation complete infection control training.
• The provider must ensure there is a local risk register in place to provide overview of local risks.

There were areas where the provider could make improvements and should:

• The provider should ensure that staff are up-to-date with their annual mandatory training and appraisals.
• Ensure incidents are consistently recorded and their severity assessed when they meet incident reporting criteria, across the three sites.
• Review the contingency plans if a break-in should occur at the Tipton site. This should include cooperation from other agencies using the facility
• Review the arrangements for general repair and upkeep of the facilities, again with the cooperation from others using the building.
• Review procedures for learning and communicating with all staff following incidents, audits and complaints.
• Ensure audit results are communicated to all staff and are supported with an action plan, review date and person responsible.
• Ensure any local risks are clearly identified and have a documented timeframe for review.
• Ensure the backlog of patient records is scanned onto the new database within an agreed period.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements.

We also issued the provider with three requirement notice(s) that affected Brook Tipton. Details are at the end of the report.