cgl spectrum newapproachcomprehensive report ... · 1 cgl spectrum quality report 23/08/2019....

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Overall rating for this location Good –––

Are services safe? Good –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Good –––

Mental Health Act responsibilities and Mental Capacity Act and Deprivation of LibertySafeguardsWe include our assessment of the provider’s compliance with the Mental Capacity Act and, where relevant, MentalHealth Act in our overall inspection of the service.

We do not give a rating for Mental Capacity Act or Mental Health Act, however we do use our findings to determine theoverall rating for the service.

Further information about findings in relation to the Mental Capacity Act and Mental Health Act can be found later inthis report.

CCGLGL SpectrumSpectrumQuality Report

St Martins House14 The CommonHatfieldAL10 0URTel: 01707256532Website: https://www.changegrowlive.org/content/spectrum-hertfordshire-drug-alcohol-services-hatfield

Date of inspection visit: 04/07/2019Date of publication: 23/08/2019

1 CGL Spectrum Quality Report 23/08/2019

Overall summary

• Spectrum had health and safety systems in place tomanage the safety for clients and staff across allhubs. Fire risk assessments and the health and safetyfolders were up to date.

• All hubs had a range of appropriate rooms to meetclient’s needs. The clinical rooms were clean,well-stocked and regularly reviewed by the clinicallead nurse. Staff had access to Naloxone (Naloxone isused to reverse the effects of opioids) and adrenalinewhich were stored in emergency grab bags at allhubs.

• The provider had robust policies, procedures &training related to medication and medicinesmanagement. These included: prescribing,detoxification and assessing people’s tolerance tomedication. Staff adhered to infection controlprinciples, including hand washing and the disposaland storage of clinical waste.

• Adverse events were planned for. The provider had abusiness continuity plan in place which was regularlyreviewed by the hub managers.

• There was enough staff at all grades to meet theneeds of the clients. All staff received mandatorytraining suitable for their role. Additional specialisttraining was provided for example, Recovery workershad access to qualifications and credit framework(QCF) diploma level three in a therapy relatedsubject. The multidisciplinary team met regularly todiscuss client progress and needs. Each day amorning meeting was held at all hubs, where theteam discussed the clients they were scheduled tosee that day.

• Clients received a comprehensive assessment in atimely manner which included a physical health

assessment. Staff were able to identify signs ofdeteriorating in mental health. Risk managementplans were discussed upon first assessment andregularly reviewed thereafter.

• The service bench marked their service performanceagainst Public Health England treatment outcomes.We were provided with performance evidence wherethe provider was performing above the Public healthEngland performance data for successfulcompletions of treatment, opiate representation,incomplete Hepatitis B vaccinations and levels ofincomplete Hepatitis C screening.

• Staff worked well with external agencies. Recoveryworkers and nurses were co located in hospitals,local authority family safe guarding team, GPsurgeries, the job centre and police custody suites.This meant staff were able to share key informationimmediately.

• Staff in leadership roles had the skills, knowledgeand experience to perform their roles and providestrong leadership to staff. Managers had a goodunderstanding of the service they were responsiblefor and could explain clearly how the teams wereworking to provide high quality care.

• Staff we spoke with told us they felt respected,supported and valued by the provider. They reportedthat work related stress was minimal andmanageable and that team morale was positive.

• There were robust governance systems in place toeffectively manage the service. The manager hadoversight of the service. Performance was monitoredby completing regular audits and the outcomes wererecorded on key performance indicator dashboards.This meant the manager could monitor performanceover a period of time to ensure continuousimprovement.

Summary of findings


Contents

PageSummary of this inspectionBackground to CGL Spectrum 5

Our inspection team 5

Why we carried out this inspection 5

How we carried out this inspection 5

What people who use the service say 6

The five questions we ask about services and what we found 7

Detailed findings from this inspectionMental Health Act responsibilities 10

Mental Capacity Act and Deprivation of Liberty Safeguards 10

Overview of ratings 10

Outstanding practice 21

Areas for improvement 21

Summary of findings


Change Grow Live- Spectrum

Services we looked at:Substance misuse services

ChangeGrowLive-Spectrum

Good –––


Background to CGL Spectrum

Change Grow Live Spectrum is part of the of a nationalChange Grow Live provider who provides a non-for-profitdrug and alcohol treatment service. Spectrum wasawarded a seven-year contract by commissioners inSeptember 2018 to deliver substance misuseinterventions for people living in the Hertfordshire region.At the time of the inspection there were 1471 clients usingthe service.

Spectrum operates a hub and spoke model. There werefour hubs at the time of inspection which were inHatfield, Watford, Hertford and Stevenage. Satellite siteswere strategically planned maximising the geographicalregion where the service was provided and accessible toclients. The service provided interventions and supportedpeople of all ages. Adults were seen at the hubs andpeople under the age of 18 were seen at home, in schoolsand colleges if required. Opening times at all four hubsvaried to ensure clients were able to access the service inthe evening and weekend.

Each hub had specialist teams and recovery workerswhich where the Opiate Team, Alcohol Team, Complexneeds Team and Engagement & Rapid Recovery.Co-located teams included, Family Safeguarding,Hospital Liaison, Integrated Criminal Justice and Family,Young People service.

Spectrum is registered with the Care Quality Commissionto provide treatment of disease disorder or injury as aregulated activity. At the time of inspection, the servicehad a registered manager in post. A registered manager isthe person appointed by the provider to manage theregulated activity on their behalf, where the provider isnot going to be in day-to-day charge of the regulatedactivities themselves.

Our inspection team

The team that inspected the service comprised two CQCinspectors and a specialist advisor nurse with specialistsubstance misuse experience.

Why we carried out this inspection

We inspected this service as part of our ongoingcomprehensive mental health inspection programme

How we carried out this inspection

To fully understand the experience of people who useservices, we always ask the following five questions ofevery service and provider:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

Before the inspection visit, we reviewed information thatwe held about the location, asked a range of otherorganisations for information and sought feedback frompatients at three focus groups. During the inspection visit,the inspection team:

Summaryofthisinspection

Summary of this inspection


• visited all four hubs, looked at the quality of theenvironment and observed how staff were caring forpatients

• spoke with five patients who were using the service

• spoke with the registered manager and managers foreach of the hubs

• spoke with 20 other staff members; including,professor, doctors, nurses, social worker andrecovery workers

• attended and observed one hand-over meetings andtwo multi-disciplinary meetings

• looked at 26 care and treatment records of patients

• carried out a specific check of medicationmanagement and clinics

• looked at a range of policies, procedures and otherdocuments relating to the running of the service.

What people who use the service say

• Clients spoken with told us they liked all staff andthat most staff were helpful however, one client wasallocated a new recovery worker without being toldwhy.

• Clients spoken with told us they knew how tocomplain and felt like they would be supported ifthey wished to raise a complaint.

• We were told by clients that volunteers and peersupport workers inspired others as they had beenthrough the were in recovery and were able to have apositive impact helping others.




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?We rated safe as good because:

• The service had robust health and safety systems in place tomanage the safety of clients and staff across all four hubs. Fire riskassessments were up to date. Where actions were identified throughthe fire risk assessments appropriate action was taken.

• All hubs had a range of appropriate rooms to meet clients for groupmeetings, one to one appointment, medical reviews and a needleexchange. Staff had access to Naloxone (Naloxone is used to reversethe effects of opioids) and adrenaline which were stored inemergency grab bags at all hubs.

• Managers had planned for adverse events. The provider had abusiness continuity plan in place which was regularly reviewed bythe hub managers.

• Managers ensured that there was enough staff at all grades to meetthe needs of the clients. The registered manager booked agencystaff to cover staff shortages and distributed work load amongst theteam.

• All staff received mandatory training suitable for their role.

• We reviewed 26 care and treatment records and found all clientshad risk management plans in place. Risk management plans werediscussed upon first assessment and regularly reviewed at clientplan reviews and three-monthly full risk reviews.

• Relevant staff had received safeguarding training.

• The provider had robust policies, procedures & training related tomedication and medicines management which included:prescribing, detoxification and assessing people’s tolerance tomedication.

However:

• The decoration at Watford hub and Hertford hub were dated andneeded redecorating.

Good –––

Are services effective?We rated effective as good because:

• Clients received a comprehensive assessment in a timely mannerwhich included a physical health assessment and on-going physicalhealth assessments as required.

Good –––




• Staff completed recovery focused care plans. Where a need wasidentified through the comprehensive assessment, the recoveryworker and client developed a person-centred care plan.

• Recovery workers supported clients to minimise risks associatedwith substance misuse. Blood borne virus testing was routinelyoffered.

• Staff used technology to support patients effectively. For example,at all four hubs there were posters promoting third party mobilephone applications that include self-help tools.

• Recovery workers regularly reviewed care and recovery plans withthe person using the service. As part of the review, recovery workersand the clients used recognised dependency tools.

• All staff received a comprehensive induction.

• The multidisciplinary team met regularly to discuss client progressand needs and there were evidence recovery workers worked closewith external agencies.

Are services caring?We rated caring as good because:

• We observed staff interacting in a kind and respectful mannerthroughout the inspection.

• Staff said they could raise concerns about disrespectful,discriminatory or abusive behaviour or attitudes to patients withoutfear of the consequences.

• Staff supported clients to understand and manage their care,treatment or condition.

• The service had clear confidentiality policies in place that areunderstood and adhered to by staff.

• The provider had developed a dual diagnosis and learningdisability joint working protocol which ensured staff sharedinformation with clients in a way they understood.

• Staff enabled families and carers to give feedback on the servicethey received for example, via surveys or community meetings,feedback reviewed was generally positive.

However

• One client told us they were allocated a new recovery workerwithout being told why. Another client told us at times whilstattending group they felt like the recovery worker didn’t listen totheir concerns all the time.

Good –––




Are services responsive?We rated responsive as good because:

• The provider had a clear documented acceptance and referralcriteria in place, that had been agreed with relevant services and keystakeholders which all staff were aware off.

• The service monitored targets for length of time, from referral totriage to comprehensive assessment and from assessment tointervention.

• Staff completed recovery and risk management plans, whichreflected the individual needs of the client. These included clearcare pathways to other supporting services for example, maternity,social and housing services.

• Managers had ensured that clients with limited mobility needswere able to attend the hubs for their reviews. The hubs had roomson the ground floor which clients with a disability could access forgroup interventions.

• The providers complaint procedure was on display at all of thehubs. Clients spoken with told us they knew how to complain andfelt like they would be supported if they wished to raise a complaint.

Good –––

Are services well-led?We rated Well-led as good because:

• The registered manager had strategic oversight of all hubs. Staff inleadership roles had the skills, knowledge and experience toperform their roles and provide strong leadership to staff.

• Staff knew and understood the vision and values of the team andorganisation and what their role was in achieving that.

• Staff we spoke with told us they felt respected, supported andvalued by the provider. They reported that work related stress wasminimal and manageable and that team morale was positive.

• Staff had access to support for their own physical and emotionalhealth needs through an occupational health service.

• Managers had ensured that there were robust governance systemsin place to effectively manage the service.

• Staff had the ability to submit items to the provider risk register.

Good –––




Mental Health Act responsibilities

We include our assessment of the provider’s compliancewith the Mental Health Act and Mental Capacity Act in ouroverall inspection of the core service.

We do not give a rating for Mental Health Act or MentalCapacity Act; however, we do use our findings todetermine the overall rating for the service.

Further information about findings in relation to theMental Health Act and Mental Capacity Act can be foundlater in this report.

Mental Capacity Act and Deprivation of Liberty Safeguards

• Staff assumed capacity in line with the MentalCapacity Act. We found evidence staff ensured clientsconsented to care and treatment, that this wasassessed, recorded and reviewed in a timely manner.

• The service promoted staff with Mental Capacity Acttraining, we found 100% of relevant staff hadcompleted the training.

Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Substance misuseservices Good Good Good Good Good Good

Overall Good Good Good Good Good Good

Detailed findings from this inspection


Safe Good –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Are substance misuse services safe?

Good –––

Safe and clean environment

Safety of the facility layout

• The service had robust health and safety systems inplace to manage the safety of clients and staff across allfour hubs. The provider had recently completed a basicligature risk assessment which was appropriate for theservice provided. The ligature risk assessment identifiedligature points throughout the building and includedcontrol measures. For example, clients were escorted toand from interview rooms and were not left unattended.Fire risk assessment and the health and safety folderswere up to date. Where actions were identified throughthe fire risks assessment, appropriate action was taken.

• The service had a range of appropriate rooms at allhubs, in order to meet clients for group meetings, one toone appointment, medical reviews and a needleexchange. The clinical rooms were clean, well-stockedand regularly reviewed by the clinical lead nurse. Theneedle exchange facilities at all four hubs were wellstocked and locked when not in use.

• Spectrum utilised CCTV to monitor public areas at allhubs. CCTV screens were in the reception area whichwere observed by reception staff throughout the day.Rooms where clients were seen had a portable panicalarm. The panic alarm had a direct link to the localpolice service. If the alarm was missing from themeeting room staff could use their personal alarm tosummon support if required.

• Staff had access to Naloxone (Naloxone is used toreverse the effects of opioids) and adrenaline whichwere stored in emergency grab bags at all hubs. Theemergency bags were regularly checked to ensure therequired medications were in date and available to use.Change grow Live did not use automated defibrillatorsor oxygen. In the need of a medical emergency staffwould call 999.

Maintenance, cleanliness and infection control

• We observed that areas where people using the servicehad access to, were generally clean and tidy. However,the decoration at Watford hub and Hertford hub weredated and needed redecorating. We were assured theprovider was actively seeking quotes from theirapproved contractors to update the decoration of theservices. All hubs had a dedicated cleaning contractcompany who attended the building daily. Cleaningrecords were up to date.

• Staff and clients were able to raise maintenance issuesby completing a maintenance request form. All jobswere logged on the database and approved contractorswere used to complete the works.

• Staff adhered to infection control principles, includinghand washing and the disposal and storage of clinicalwaste. Spectrum had a contract in place with a clinicalwaste company who regularly disposed of the waste. Allsites had a hatch in the toilet where clients couldtransfer urine pots used for screening analysis whichminimised the risk of cross contamination of publicareas.

• Adverse events were planned for. The provider had abusiness continuity plan in place which was regularlyreviewed by the hub managers. The continuity plan

Substancemisuseservices

Substance misuse services

Good –––


details actions to take in the need of a building failure.The provider recently had a flood at the Stevenage site.Staff adhered to the contingency plan and clients wereseen at agreed locations. Approved contractors wereused to repair the burst pipe in a timely manner.

Safe staffing

• There was enough staff at all grades to meet the needsof the clients. Spectrum employed a total of 101substantive staff and 51 volunteers. The staff range ofhealth care professionals ranging from a professor,consultant psychiatrist, social workers, psychologist,non-medical prescribers, nurses, managers andrecovery workers, administration staff and a lead dataanalysist. At the time of inspection, the provider had onenurse vacancy to cover maternity leave and tworecovery worker vacancies.

• The registered manager planned for staffing shortagesby booking agency staff and distributing work loadamongst the team. The number of staff on shiftmatched the providers’ staffing requirements at thetime of inspection.

• Spectrum had a proactive approach to anticipatingfuture problems including staffing levels and staffabsence. When a member of staff was planning to go onleave they completed a portfolio handover form, thatdetailed key information such as planned appointmentsand high clients to ensure continuity of care.

• Managers monitored the recovery workers caseloads.The provider did not use a formal caseloadmanagement tool however, we were told caseloadswere generally manageable. Recovery workers workingwith high risk clients had a smaller case load thanrecovery workers working with clients deemed a lowerrisk. This was to ensure patient safety and maximisetreatment outcomes for clients.

Mandatory training

• All staff received mandatory training suitable for theirrole. The provider set a 75% completion target whichwas monitored by hub managers and the registeredmanager. We found all mandatory online trainingcourses were above 75% compliant. Mandatory trainingincluded, Mental Capacity Act, basic life support,equality and diversity, health and safety, safeguardingchildren and adults.

• Staff told us they were aware of the lone workingprocedure which included working with clients at thehubs, satellite sites and home visits. We were told if aclient was high risk they would be seen by two workers.

• The registered manager had recently reviewed theirtraining programme to ensure all staff have access totheir mandatory training in a timely manner. All staffwere expected to complete online training during theirinduction period. In addition, staff were expected tocomplete face to face training, which was delivered intwo week blocks three times per year. Managers spokenwith told us this helped ensure staff were up to datewith their mandatory training but also minimised theimpact to service delivery as they could plan to coverstaff who were planned to attend the training.

• Training courses covered on the two-week face to facetraining blocks were; overview of all service pathways,suicide prevention, professional boundaries, bloodborne viruses, take home naloxone, motivationalinterviewing, dual diagnosis, learning disabilitiesawareness and working with local mental healthtraining services, embedding knowledge and learningafter incidents.

Assessing and managing risk to patients and staff

• We reviewed 26 care and treatment records and foundall clients had risk management plans in place.Spectrum held all records on their electronic database.The risk assessments were detailed and covered areassuch as, mental health, domestic violence, sexualexploitation and safeguarding risks.

• Staff discussed risk management plans on firstassessment and regularly reviewed these at client planreviews and three-monthly full risk reviews. Riskassessments also included reintegration to treatmentplans for clients who unexpectedly left treatment.

• Competent staff assessed client’s physical health duringthe first assessment. Where physical health concernswere identified or if the client was prescribed by theservice, their physical health was monitored byappropriately trained staff. Staff told us if they identifiedwarning signs through regular engagement they wouldadvise the client to seek urgent medical health. We were



Good –––


given an example where a client presented with physicalhealth concerns. Staff supported the client to attend thelocal accident and emergency service to receiveappropriate support.

• We saw evidence recovery workers promoted harmreduction and offered advice and were signposted toaccess third party services to meet their needs.

• Staff spoken with were aware of personal safetyprotocols and the lone working procedure. All staff hada work mobiles phone and were expected to keepregular contact with their team. Where recovery workerswere meeting with high risk clients they would meetwith them in pairs.

Management of service user risk

• Staff informed clients of the risks of continuedsubstance misuse. We found evidence all recordsreviewed of harm minimisation and safety planning wasan integral part of recovery plans.

• Where clients continued to use substances, the clinicalteam supported clients to the achieve optimaltherapeutic dose required to try and prevent them fromseeking more drugs.

• Staff held daily flash meetings at all hubs. We observedstaff engaging in detail conversations regarding clientrisks. Where appropriate the service shared riskinformation with key stakeholders such as the localauthority and probation service.

• Staff adhered to best practice in implementing asmoke-free policy across all hubs.

• Nursing staff stored Naloxone in clinic rooms at alllocations. Naloxone is a drug that can reverse the effectsof opioids and prevent death if used within a shortperiod following an opioid overdose. All staff weretrained in administering Naloxone and knew where toaccess it in the case of an emergency.

• Staff were able to identify signs of deteriorating mentalhealth. The consultant psychiatrist advised staff whatsigns to look for. These included non-engagement withtreatment. We found evidence were clients did notengage in treatment the provider took appropriate

action. For example, recovery workers contacted theclient by their preferred method of communication andencouraged the client to collect their script from a hubrather than the pharmacy.

Safeguarding

• Staff had received safeguarding training. Staff could giveexamples of how to protect clients from harassment anddiscrimination, including those with protectedcharacteristics under the Equality Act. Staff spoken withwhere able to describe the process to raise asafeguarding. There was further information informingstaff and clients how to raise a safeguarding on displaythroughout the hubs.

• Staff worked effectively within teams, across servicesand with other agencies to promote safety includingsystems and practices in information sharing. Forexample, recovery workers were co located with thelocal authority family safeguarding team. This meantthey were able to rapidly identify and engage withclients who have identified safeguarding risks.

• We reviewed a random sample of incidents and foundthe provider had a robust system in place for reportingsafeguarding incidents. Each of the four hubs had adesignated safeguarding lead.

Staff access to essential information

• The provider used an electronic patient recordingsystem. The system was easy to use and track patients.Recovery workers updated the system regular includingafter appointments and interventions.

• All relevant staff had access to the system and hadprompt access to care records that were accurate andup to date.

• Where a patient transferred to a new team due torelocating there were no delays in staff accessing theirrecords.

Medicines management

• The provider had robust policies, procedures & trainingrelated to medication and medicines managementwhich included: prescribing, detoxification andassessing people’s tolerance to medication.



Good –––


• The storage and processing of prescriptions was robust.There were clear guidelines in place for the security ofthe management of prescriptions that staff followed.

• All staff were trained in administering Naloxone.

• Medication rooms were clean and tidy. All equipmentwas calibrated regularly. There was evidence of robustaudits and checks of the clinic rooms were completeregularly by the clinical lead nurse.

• The service had good links with local pharmacies.Where prescriptions were not collected the pharmacyinformed the recovery workers who took appropriateaction. For example, if a client did not collect a script forthree days they were medically reviewed by theproviders doctor before reissuing the prescription.

• The service had systems to ensure staff knew aboutsafety alerts and incidents, so patients received theirmedicines safely.

• Clinical staff reviewed the effects of medication on theclient’s physical health regularly. We saw were clientswere prescribed by the providers prescribers, that theclients had up to date GP summaries, and that ECG’sand further blood tests were recorded as required, inline with best practice.

Track record on safety

• The service did not report any serious incidents over thelast 12 months prior to inspection. We reviewed arandom sample of incidents and did not find anyincidents which met the threshold to be classified as aserious incident.

Reporting incidents and learning from when things gowrong

• All staff knew what incidents to report and how to reportthem. The service used an electronic incident reportsystem to track and log incidents.

• Staff reported incidents in line with national guidanceand statutory requirements.

• Staff told us they were clear about their roles andresponsibilities for reporting incidents and reportedincidents in a consistent way.

• Staff understood the duty of candour. They were openand transparent, and gave people using the service andtheir families a full explanation when something wentwrong.

• There was evidence that changes had been made as aresult of feedback. We observed an integratedgovernance team meeting where staff discussedlearning from incidents in detail. Learning pointsidentified were both areas for improvement but alsonotable practice for good examples of interventionsdelivered.

Are substance misuse services effective?(for example, treatment is effective)

Good –––

Assessment of needs and planning of care

• We reviewed 26 care and treatment records and foundthat clients received a comprehensive assessment in atimely manner which included a physical healthassessment. Clients were triaged by the single point ofaccess team who completed an initial triage form andthen scheduled a formal face to face assessment with arecovery worker within five days.

• Physical health screening was routinely complete whereclients were prescribed by the provider as part of clientscare and treatment. For example, physical observationsand baseline bloods were complete to help informappropriate treatment, including when prescribing anddetoxification regimes.

• Staff completed recovery focused care plans. Where aneed was identified through the comprehensiveassessment, the recovery worker and client developed aperson-centred care plan. Client records clearly recordtreatment rationales in line with NICE prescribing anddetoxification guidelines.

• Staff considered clients mental capacity to agree totreatment and interventions, at core assessment stage.

• Staff regularly reviewed individual needs and recoveryplans, including risk management plans. Staff updatedcare plans when necessary for example after thethree-monthly formal risk review and after an incident.



Good –––


• Staff developed a risk management plan for thosepeople identified as being at risk that included a planfor unexpected exit from treatment. The plans includedthe clients preferred communication method.

Best practice in treatment and care

• Staff provided a range of care and treatmentinterventions suitable for the patient group. Theinterventions were recommended by, and weredelivered in line with, guidance from the NationalInstitute for Health and Care Excellence. These includedmedication and psychological therapies.

• Recovery workers supported clients to minimise risksassociated with substance misuse. For example, allfound hubs had a needle exchange service which isrecommended by the Department of Health drugmisuse guidelines. The service offered safe storageboxes where clients had indicated a child lived at theirproperty.

• Blood borne virus testing was routinely offered. Theprovider was working closely with an NHS trust whofacilitated regular Hepatitis C clinics, which we were toldhad been effective in supporting and treating clients.

• Staff supported patients to live healthier lives. Forexample, healthy eating advice, managingcardiovascular risks, and how to access services such asthe dentist and opticians.

• Staff used technology to support patients effectively. Forexample, at all four hubs there were posters promotingthird party mobile phone applications that includeself-help tools.

• The provider was able to support clients with bothinpatient and community detox. Where a client was instable accommodation and wanted to detox frommedication the service supported the detox with athird-party provider. The provider had a list of preferredresidential detox providers which were used for clientswho did not have stable accommodation and requireddetoxification.

Monitoring and comparing treatment outcomes

• Recovery workers regularly reviewed care and recoveryplans with the person using the service. As part of thereview recovery workers and the clients used recogniseddependency tools such as SAD-Q, AUDIT and TOPS tomonitor treatment outcomes.

• Managers bench marked their service performanceagainst Public Health England treatment outcomes. Wewere provided with performance evidence where theprovider was performing above the Public healthEngland performance data for successful completions oftreatment, opiate representation, incomplete HepatitisB vaccinations and levels of incomplete Hepatitis Cscreening.

Skilled staff to deliver care

• The service had enough staff with the right skills to meetthe needs of the clients. Staff had access to specialisttraining for their role. For example, the associate doctorwas given funding to complete their MSc in psychiatry.Recovery workers had access to qualifications andcredit framework (QCF) diploma level three in a therapyrelated subject.

• All staff were provided with a comprehensive induction.This included mandatory training, information aboutthe service and a period of shadowing recovery workers,before they worked independently with clients. Staffwere expected to complete a six-monthcompetency-based assessment which was reviewed bytheir line manager at regular intervals. This assessmenthelped in identity training needs and ensured all staffwere competent working with clients.

• Managers identified the learning needs of staff andprovided them with opportunities to develop their skillsand knowledge through supervision and careerprogression discussions. Staff received specialisttraining for their role which included, relapseprevention, harm reduction and motivationalinterviewing, non-medical prescribing. Staff we spoke totold us they received regular supervision in line with thecompany policy. There was a clear supervision structurein place. All staff knew who their supervisor was.

• The service ensured that robust recruitment processeswere followed. We reviewed five human resourcerecords and found that all staff had received the relevantrecruitment checks including a disclosure baring service



Good –––


(DBS), references, application form and job description.Where disclosers were declared on the disclosure baringservice record the registered manager completed a riskassessment.

• Poor staff performance was addressed promptly andeffectively. We saw evidence where performanceconcerns were identified the provider took appropriateaction in a supportive manner.

• Staff valued volunteers as members of the staff team.We saw managers recruited volunteers when requiredand trained and supported them for the roles theyundertook.

Multi-disciplinary and inter-agency team work

• The multidisciplinary team met regularly to discussclient progress and needs. A morning meeting was helddaily in all hubs, where the team discussed the clientsthey were scheduled to see that day. Details discussedincluded risk information. A hub manager haddeveloped a complex case review meeting wererecovery workers presented their complex clients to themultidisciplinary in more detail for advice and supporthow to manage the client. We were told the complexcase meeting has had a positive impact whilstsupporting clients with complex needs.

• There was evidence that recovery workers worked closewith external agencies. Recovery workers and nurseswere co located in hospitals, local authority family safeguarding team, GP surgeries, the job centre and policecustody suites. This meant staff were able to share keyinformation immediately.

• Staff completed recovery plans with clients, whichincluded clear care pathways to third supportingservices. For example, the local homelessnessintervention team and after care support groups. Theservice discharged people when specialist care was nolonger necessary and worked with relevant supportingservices to ensure the timely transfer of information.

• The service developed an end of life pathway whichensured that staff were able to continue their work withclients who had life limiting conditions. We observed ameeting where staff shared the good joint workingbetween local end of life cancer charity and recoveryworkers.

Good practice in applying the Mental Capacity Act

• Staff assumed capacity in line with the Mental CapacityAct. We found evidence staff ensured clients consentedto care and treatment, that this was assessed, recordedand reviewed in a timely manner.

• The service had a policy on the Mental Capacity Actwhich staff were aware of and could refer to.

• The service promoted staff with Mental Capacity Acttraining, we found 100% of relevant staff had completedthe training.

Are substance misuse services caring?

Good –––

Kindness, privacy, dignity, respect, compassion andsupport

• We observed staff interacting in a kind and respectfulmaner throughout the inspection.

• Clients spoken with told us they liked all staff and thatmost staff were helpful. Staff were able to demonstratethat they knew their clients’ preferences and needs well.However, one client told us they were allocated a newrecovery worker without being told why. Another clienttold us at times whilst attending group they felt like therecovery worker didn’t listen to their concerns all thetime.

• Clients told us that volunteers and peer support workersinspired others as they had been through the addictionprocess and was able to have a positive impact helpingothers.

• Staff said they could raise concerns about disrespectful,discriminatory or abusive behaviour or attitudes topatients without fear of the consequences. We saw allclient accessible rooms had a poster displayingexpectations of behaviour which all clients and stafffollowed.

• We saw evidence that staff supported clients tounderstand and manage their care, treatment orcondition through interventions, group work, self-helpand information leaflets.



Good –––


• Staff signposted patients to other services whenappropriate and, if required, supported them to accessthose services, for example to the local housing serviceand job centre.

• The service had clear confidentiality policies in placethat were understood and adhered to by staff. Staffmaintained the confidentiality of information aboutpatients. A confidentiality and information sharingagreement was in place, of which all staff knew aboutand understood. The agreement was stored on withinthe client’s electronic record.

Involvement in care

• Staff communicated with clients in a way that theyunderstood their care and treatment, including findingeffective ways to communicate with clients withcommunication difficulties. The provider had developeda dual diagnosis and learning disability joint workingprotocol which ensured that staff shared informationwith clients in a way they understood. The providerswebsite also had a tool that played audio informationfor individuals who were unable to read. All informationregarding treatment options was available in a variety oflanguages, audio, and easy read.

• The service had access to appropriate advocacy forpeople who use services their families and carers.

• We found all clients using the service had a recoveryplan and risk management plan in place, thatdemonstrated the person's preferences, recovery capitaland goals.

• Staff engaged with people using the service, theirfamilies and carers to develop responses that met theirneeds and ensured they had information needed tomake informed decisions about their care.

• Staff actively engaged people using the service, theirfamilies and carers where appropriate, in planning theircare and treatment where required.

Involvement of families and carers

• Staff enabled families and carers to give feedback on theservice they received for example, via surveys orcommunity meetings. Feedback reviewed was generallypositive.

• Staff provided carers with information about how toaccess a carer’s assessment.

• We were told a family member or significant others wereoffered follow up telephone support at an agreed timefollowing the death of a loved one.

Are substance misuse services responsiveto people’s needs?(for example, to feedback?)

Good –––

Access and discharge

• The provider had alternative care pathways and referralsystems in place for people whose needs cannot be metby the service. For example, where a client’s mentalhealth was impacting upon their addiction’s clients werereferred to a community mental health team for furtherreview.

• The service offered alternative treatment options if aperson was not able to comply with specific treatmentrequirements. For example, where a client had theirprescription from the chemist, the service arranged withthe client to collect the prescription from the local hub,to try and re-engage with them and offer an alternativeintervention.

• The service had agreed response time for acceptingreferrals. Most referrals were managed through theirsingle point of access team. Waiting times were low andmost clients were offered a face to face assessmentwithin five days. However, referrals from the acutehospital and police custody suite were manage in colocated sites which meant recovery works and thenurses were able to triage, engage and offer anintervention the same day.

• The provider had clear documented acceptance andreferral criteria that has been agreed with relevantservices and key stakeholders which all staff were awareof.

• The service monitored targets for time from referral totriage to comprehensive assessment and fromassessment to intervention. There were someanomalies and outliers in the data. Where there was a



Good –––


delay and the targets were not met, there was mitigatingfactors. For example, referrals being received fromprisons and hospital in patient wards where patientswere discharged later than planned.

• Staff ensured that recovery and risk management plansreflected the individual needs of the client, includingclear care pathways to other supporting services forexample, maternity, social and housing services.

• Staff planned for patients’ discharge, including goodliaison with care managers and co-ordinators. We sawevidence that the hub manager discussed discharge aspart of supervision with staff. This ensured that clientswere being discharged in a timely manner with supportoptions from third party providers.

• Staff supported patients during referrals and transfersbetween services, for example, if they requiredtreatment in an acute hospital for medical treatment.

The facilities promote recovery, comfort, dignity andconfidentiality

• All hubs had a secure waiting area. When a clientattended the site, they had to ring the intercom systemand were let in by reception staff.

• The hubs had rooms on the ground floor which meantclients with limited mobility needs were able to attendthe hubs for their reviews and group interventions ifthey were able too. All rooms were clients were seenwere private and the rooms were lockable. The hubshad a kitchen were clients were able to make snacksand drinks throughout the day.

• Staff we spoke with told us they encouraged patients todevelop and maintain relationships with people thatmattered to them, both within the services and thewider community.

• The provider encouraged clients to access third partygroups in the local community and activities to aid theirrecovery. For example, accessing educational and workopportunities.

Meeting the needs of all people who use the service

• Staff demonstrated an understanding of the potentialissues facing vulnerable groups for example, clients whohad experienced domestic abuse and female sexworkers were able to access a woman’s only service.

• All hubs had equality and diversity champions whopromoted the equal rights of all clients. These includedlesbian gay bisexual transgender and back and ethnicminorities.

• Managers had implemented a single point of access toensure clients who self-refer and are referred in to theservice, are triaged and offered an assessment withoutdelay. Since the implementation of the single point ofaccess, clients have been triaged and signposted to theappropriate intervention team in a timely manner.

• People using services told us that care and treatmentwas rarely cancelled. When a member of staff went onleave, they complete a client handover form. Thisensured that the person covering their client portfoliohas accurate, up to date information.

Listening to and learning from concerns andcomplaints

• Staff told us they would protect patients who raisedconcerns or complaints from discrimination andharassment.

• The provider’s complaint procedure was on display atall of the hubs. Clients spoken with told us they knewhow to complain and felt like they would be supported ifthey wished to raise a complaint. Suggestion boxes werepaced in all reception areas. At the time of inspectionthere were no suggestions in the boxes.

• Complaints records demonstrated that individualcomplaints have been responded to in accordance withthe providers complaint policy. In total the service hasreceived 10 formal complaints and 61 compliments overthe last 12 months prior to inspection. We reviewed arandom sample of complaints and found the providerhad taken appropriate action.

• We saw evidence that hub managers discussedcomplaints at hub meetings. Staff told us that if therewas learning from a complaint, they would be told viameetings and that emails were also sent to their workemail address.



Good –––


Are substance misuse services well-led?

Good –––

Leadership

• The registered manager had strategic oversight of allhubs. Staff spoke highly of the registered manager andtold us they had confidence in the manager leading theservice.

• Staff in leadership roles had the skills, knowledge andexperience to perform their roles and provide strongleadership to staff. Managers had a good understandingof the service they were responsible for and couldexplain clearly how the teams were working to providehigh quality care.

• Staff told us managers were visible in the service andapproachable for clients and staff.

Vision and strategy

• Staff knew and understand the vision and values of theteam and organisation and what their role was inachieving that. The provider was in the process ofupdating their vision and values after consulting staffand clients.

• Staff had a good understanding of their role andresponsibilities. We found all staff had a job description.

• Staff had the opportunity to contribute to discussionsabout the strategy for their service, especially where theservice was changing. Staff we spoke with werepassionate about the service and told us they wereinvolved with the recent restructure after being awardedthe new seven-year contract.

Culture

• Staff we spoke with told us they felt respected,supported and valued by the provider. They reportedthat work related stress was minimal and manageableand that team morale was positive.

• Staff told us they felt positive and proud about workingfor the provider and their team. Staff held regular careerprogression conversations with their line managers. Twonurses were sponsored by the service to complete their

non-medical prescriber training, the senior socialworker had completed family therapy training and thedoctor had been supported to complete their MSc inpsychiatry.

• The service had a policy in place to manage andsupport staff who were subject to bullying andharassment. At the time of inspection there were nobullying or harassment cases.

• Staff had access to support for their own physical andemotional health needs through an occupational healthservice.

• Staff reported that the provider promoted equality anddiversity in its day to day work and in providingopportunities for career progression.

• Teams worked well together and where there weredifficulties managers dealt with them appropriately.

Governance

• There were robust governance systems in place toeffectively manage the service. Governance policies,procedures and protocols were regularly reviewed andimproved to ensure the service delivered safe, goodquality interventions in line with national best practice.

• There was a clear framework and agenda of what mustbe discussed in team meetings, in order to ensure thatessential information, such as learning from incidentsand complaints, were shared and discussed.

• Mortality meetings were held every two weeks. Staff hadimplemented recommendations from reviews of deaths,incidents, complaints and safeguarding alerts at theservice level.

• Staff undertook or participated in local clinical audits.We reviewed a random sample of the qualityimprovement audits and found staff had acted wereareas for improvement had been identified.

• Data and notifications were submitted to externalbodies and internal departments as required. Forexample, safeguarding referrals were sent to the localauthority and the Care Quality Commission.

• Where staff were co located they had a clearunderstanding of the arrangements for working withother teams, both within the provider and external, tomeet the needs of the patients.



Good –––


• The service had a whistle blowing policy in place andstaff we spoke with told us they were confident theyunderstood how to use it.

Management of risk, issues and performance

• There was a clear quality assurance management andperformance framework in place that were integratedacross all organisational policies and procedures.

• Staff maintained and had access to the risk register athub level. Staff at facility level could escalate concernswhen required. The risk register was stored on theelectronic system datix. We reviewed the risk register forthe last six months and found the provider had takenappropriate action to mitigate risks identified.

• Staff had the ability to submit items to the provider riskregister.

• The service had plans for emergencies, for example,adverse weather, a flu outbreak and incidents thatprevent the service from operating. The Stevenage sitehad experienced a flood recently. As a result, the servicewas closed for one day and utilised the providerscontingency plan. The plan worked as designed,approved contractors were used to repair the flood andthe service resumed as normal the following day.

• Managers had oversight and monitored sickness andabsence rates. The overall sickness rate for 12 monthsleading up to the inspection was 4.8%.

Information management

• Staff had access to the equipment and informationtechnology needed to do their work. The informationtechnology infrastructure, including the telephonesystem, worked well and helped to improve the qualityof care.

• Information governance systems includedconfidentiality of patient records.

• All staff had access to the right information to fulfil theirrole for example, the doctor had access to theprescription database and managers had access toaccurate, information to support them with theirmanagement role. This included information on theperformance of the service, staffing and patient care.The service employed a lead data analyst to collect datafrom facilities and directorates that were notover-burdensome for frontline staff.

• Staff spoken with had a good understanding of patientconfidentiality and clearly explained the process forsharing of information and data.

Engagement

• Staff, clients and carers had access to up-to-dateinformation about the work of the provider and theservices they used, for example on the providers websiteand via newsletters. Information available ranged fromjob vacancies, harm reduction information, and supportadvice.

• Patients and carers had opportunities to give feedbackon the service they received in a manner that reflectedtheir individual needs. The service had recently piloted aservice called care opinion where carers and clientscould give real time feedback anonymously is theywished to do so.

• Directorate leaders engaged with external stakeholders– such as commissioners through quarterly contractmonitoring meeting and monthly quality reviewmeetings. The providers senior manager also co-chairs ajoint governance meeting with local community mentalhealth providers every three months.

• Spectrum had structures in place for hub leaders andrecovery workers to discuss joint cases and partnershipworking with community mental health team colleaguesthrough locality-based Quadrant meetings every sixweeks.

Learning, continuous improvement and innovation

• Managers we spoke to demonstrated a passion forlearning and continuous improvement. Theorganisation encouraged creativity and innovation toensure up to date evidence-based practice isimplemented and embedded.

• Examples of innovative practice or involvement were:new mothers being offered reviews at multidisciplinaryclinical meetings for a period of six months post-birth toensure a comprehensive ongoing assessment of themother’s needs were complete. The clinical nurse leadhas been working with and supporting Hertfordshireand West Essex, to develop a dementia pathway for theregion which is on-going. Spectrum and the locallearning disability services have created a joint workingprotocol to improve joint working, training and referralpathways.



Good –––


Areas for improvement

Action the provider SHOULD take to improve

• The provider should ensure that clients are toldwhen they are allocated a new recovery worker.

• The provider should ensure that all premises aremaintained to an appropriate and therapeuticstandard.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


cgl spectrum newapproachcomprehensive report ... · 1 cgl spectrum quality report 23/08/2019....

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