16 May 2017
During an inspection looking at part of the service
We do not currently rate independent standalone substance misuse services.
We found the following areas of good practice:
- The service had responded to the areas of concern identified in the previous inspection. We found that the service had improved systems and processes related to the management of staff. A new system had been introduced to monitor compliance with mandatory training. Staff files showed that staff consistently received an annual appraisal and regular supervision. The service had updated checks with the disclosure and barring service for all staff. The service had undertaken a specific check of all staff member’s ‘right to work’ documentation.
- The service had introduced a risk register and had taken action in response to issues highlighted during the previous inspection related to environmental risks. Client records showed that the service’s approach to assessing and managing clients’ risks had improved since the last inspection. Client records showed that clients were offered blood born virus testing within recommended timescales.
- Staff awareness of the duty of candour had improved since the last inspection and all staff were able to provide a detailed description of the duty of candour and scenarios where it would apply. The service had introduced an electronic register to record incidents and there was evidence that notifiable incidents were consistently reported to the Care Quality Commission.
However, we found the following issues that the service provider needs to improve:
- Whilst all of the actions identified in the previous inspection that the provider must take to improve had completed, two of the three actions identified in the previous inspection that the provider should take to improve had not been completed. The service had not introduced an annual audit cycle and the whistleblowing policy and equality and diversity policy were still overdue for review.
- There were issues with the electronic database used to record dates for annual appraisal which meant that compliance data was unreliable.