10 and 11 December 2018
During a routine inspection
We rated the service as good because:
- Feedback from clients and carers was very positive. Staff supported clients in a very caring way to participate in activities run by the service and in the community.
- Staff responded to changing risks to clients, or posed by them.
- The service provided a robust prescribing and therapeutic programme tailored to the needs of clients and in line with National Institute for Health and Care Excellence guidelines.
- The service used newly appointed staff to specifically reduce the number of clients not attending appointments by identifying those at risk of disengaging from or experiencing unplanned exit from the service during treatment. They contacted those at risk between appointments and co-ordinated their care and treatment between teams with CGL Manchester.
However;
- There was a breach of infection control with wet mops and cloths not stored correctly to the extent that they were being stored over unopened boxes of needles for the needle exchange. The boxes were wet.
- In one location a security door was damaged allowing the public uncontrolled entry.
- The provider should review its current infection control training to understand whether it is adequate for the needs of the service
- Clients’ care records were not always updated in a consistent format. Individual care and recovery plans were not updated as individua plans. Instead staff updated the ‘contacts’ section with all new information. New users of the system would be unclear were to access current information or assessments.
- Management systems were not always effective. Despite monthly clinical audits being completed the issue of safe storage of cleaning equipment and needles for the needle exchange was not identified. There was a failure to maintain the buildings environments to a safe standard.