15-16 December 2015
During a routine inspection
We do not currently rate substance misuse services.
We found the following areas of good practice :
- there were enough staff to meet the needs of clients
- staff had the necessary skills and had access to appropriate training
- procedures for safeguarding clients from abuse were robust and staff demonstrated a clear understanding of them
- staff reported incidents or harm or risk of harm and recorded them appropriately and the service had a good system to review and learn from incidents
- staff carried out comprehensive assessments of clients’ needs in a timely manner
- staff followed appropriate best practice guidelines
- the service worked effectively with a range of other organisations to provide an holistic approach to meet the needs of clients
- clients had opportunities to feed back about their care and be involved in decisions about the service.
However, we also found areas that the provider could improve:
- the fire doors in the first floor kitchen did not meet British standard requirements
- safeguarding alerts were not being recorded on the incident reporting system, in line with the provider’s policy
- ongoing assessment of risk to clients was not fully documented in recovery plans, some of which were not comprehensive and did not show evidence of the involvement of clients
- recovery capital was not being discussed with people who used the service to inform treatment planning
- clinical audits were not being undertaken
- staff had not received formal training on the Mental Capacity Act.