sandwell alcohol service newapproachcomprehensive report ... ·...

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

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.

Overall summary

We do not currently rate independent standalonesubstance misuse services.

SandwellSandwell AlcAlcoholohol SerServicviceeQuality Report

Alberta Building128B Oldbury RdSmethwickB66 1JETel: 0121 553 1333Website: https://www.swanswell.org

Date of inspection visit: 4 - 5 July 2016Date of publication: 15/08/2016

1 Sandwell Alcohol Service Quality Report 15/08/2016

We found the following areas of good practice:

• Clients told us that they felt valued and respected bystaff in a safe and supportive environment. Staffpromoted choice and dignity during their interactionswith clients.

• Positive outcomes for clients using the service wasabove the national average. Re-presentation ratesfollowing treatment were low. The service was meetinglocal and national referral to assessment targets forclients new to the service.

• The service had built effective links with otherorganisations including the police, probationaryservice and health services. There was evidence ofclose working with local safeguarding structures andsocial services. The service provided outreach work inthe community to promote inclusion and access forclients across the borough.

• Staff completed risk assessments and care plans thatdemonstrated an awareness of individual clientsneeds. Staff provided harm reduction advice andpsychosocial interventions to aid clients recovery.

• Staff had access to mandatory training and additionalspecialist training to ensure they were suitably skilledand qualified. Supervision of staff took placefrequently and all staff had received an appraisal in the12 months prior to our inspection. Disclosure barringchecks were completed and professional registrationwas monitored for qualified staff.

• Staff adhered to national guidance for the prescriptionof medication. The service worked with local generalpractitioners to ensure physical health checks werecompleted prior to commencement of communitydetoxification programmes.

• Interview rooms had alarms for staff to use and thesewere checked weekly. All client and staff areas werevisibly clean and tidy and the clinic room in use by theservice was well equipped. Regular checks were madeof fridge temperatures used for the storage ofmedication and records were maintained to evidencethis.

• Staff morale was high. Feedback from staff we spokewith was that the team worked well together andsupported each other when required. Local andregional managers were accessible and all staff feltable to raise concerns if necessary.

However:

We also found the following issues that the serviceprovider needs to improve:

• The service did not have clear procedures in place forthe safe storage and dispensing of prescription pads.We made the registered manager aware of this andaction was taken to improve this following ourinspection.

• All care records did not show evidence of being writtenin a style that evidenced client involvement.

• The provider had not carried out a satisfaction surveyfor clients using the service.

Summary of findings


Contents

PageSummary of this inspectionBackground to Sandwell Alcohol Service 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 Capacity Act and Deprivation of Liberty Safeguards 11

Outstanding practice 24

Areas for improvement 24

Summary of findings


Sandwell Alcohol Service

Services we looked at:Substance misuse services.

SandwellAlcoholService


Background to Sandwell Alcohol Service

Swanswell is a national recovery charity with a vision toachieve a society free from problem alcohol and druguse.

Sandwell Alcohol Service is part of the Swanswell groupand is the single point of contact for support with alcoholmisuse issues in the Sandwell borough of the WestMidlands.

Services that are provided by Sandwell Alcohol Serviceinclude:

• community tier 2 support for clients who are notalcohol dependent and have non-complex needs

• community tier 3 support for clients with complexneeds/alcohol dependency including the provision forcommunity detoxification programmes

• alcohol treatment requirement interventions• assessment for blood borne virus screening

• support for clients to address debt, housing and legalissues

• multi agency work including with the probationservices, social services, general practitioners and thepolice

• outreach work at local general practitioner surgeries,community centres and a six day a week hospitalliaison service.

Regulated activities that Sandwell Alcohol Service isregistered with the CQC to provide are:

• Diagnostic and screening procedures

• Treatment of disease, disorder and injuries.

At the time of our inspection a registered manager was inplace and had been since 2014. There had not been aprevious inspection of this service by the Care QualityCommission.

Our inspection team

The team that inspected the service comprised CQCinspector Jon Petty (inspection lead), two other CQCinspectors, an inspection manager, one specialist advisorsubstance misuse nurse and an expert by experience.

An expert by experience is a person who has personalexperience of using, or supporting someone using,substance misuse services.

Why we carried out this inspection

We inspected this service as part of our comprehensiveinspection programme to make sure health and careservices in England meet the Health and Social Care Act2008 (regulated activities) regulations 2014.

How we carried out this inspection

To understand the experience of people who useservices, we ask the following five questions about everyservice:

• is it safe

• is it effective

• is it caring

• is it responsive to people’s need

• is it well led?

Summaryofthisinspection

Summary of this inspection


Before the inspection visit, we reviewed information thatwe held about the location, asked other organisations forinformation and collected feedback from people whohad used the service.

During the inspection visit, the inspection team:

• visited the service, looked at the quality of thephysical environment, and observed how staff werecaring for clients

• spoke with seven clients

• spoke with the registered manager and the leadnurse

• spoke with the regional operations director andmedical director.

• spoke with 17 other staff members employed by theservice provider, including team leaders, substancemisuse workers, recovery workers and administrativestaff

• received feedback about the servicefrom four stakeholders, including commissioners

• spoke with one peer support volunteer

• attended and observed two team meetings and apeer support meeting for clients

• collected feedback using comment cards from 14clients

• looked at 20 care and treatment records for clients

• looked at four sets of care records relating tocommunity detoxification programmes

• looked at policies, procedures and other documentsrelating to the running of the service.

What people who use the service say

All people that we spoke with were very positive abouttheir experiences of using the service. Clients told us thatthe service was compassionate, respectful and caring. Wewere told that staff treated clients with dignity, took timeto listen to their concerns and went the extra mile whenworking with them. Staff were described as brilliant andinspirational.

Stakeholders that we spoke with were also very positiveabout the service and told us that the service workedeffectively with other agencies and had the needs of theclient at the forefront of their business. We were also toldthat the service performed a very valuable role in workingwith clients in the community and worked pro actively toengage them in their recovery.




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?We do not currently rate standalone substance misuseservices.


• Interview rooms were fitted with panic alarms, these werechecked regularly. Staff were aware of the lone working policyand adhered to it when working out of the office with clients.

• All areas were visibly clean and tidy. Safe processes were inplace for the storage and disposal of medication. Staffmaintained equipment used for physical health monitoring andensured it was calibrated in line with manufacturersrecommendations.

• Sickness and vacancy rates were low. Staff reported thatcaseloads were regularly reviewed and there were no clientsawaiting allocation of a keyworker at the time of our inspection.

• Most staff were up to date with mandatory training and theaverage compliance rate for attendance was 83%. The servicewas in the process of introducing an electronic training recordto monitor and increase staff training rates.

• Staff completed risk assessments with clients and updatedthem regularly.

• The service had a safeguarding lead who maintained effectivelinks with local safeguarding structures. Staff appropriatelyidentified and reported safeguarding concerns, which theydocumented in clients' care records.

However, we also found the following issues that theservice provider needs to improve:

• The service did not have clear procedures in place for the safestorage and dispensing of prescription pads.Staff did notalways accurately complete documentation to enable theservice to track prescriptions and ensure they were storedsecurely. We made the registered manager aware of this at thetime of our inspection and they took action to resolve this.




Are services effective?We do not currently rate standalone substance misuseservices.


• Staff planned care and treatment with clients that took intoaccount their range of needs and offered all clients advice onharm reduction.

• Staff prescribed medication in line with guidance from theNational Institute for Health and Care Excellence. A clinical leadnurse was in post and carried out physical health monitoringfor clients undertaking community detoxification programmes.

• A support worker was employed by the service to assist clientswith debt and housing needs. Staff also offered a range ofpsychosocial interventions to aid clients recovery.

• Staff used rating scales and outcome measures to audit theeffectiveness of interventions offered by the service. The servicesubmitted their outcome data locally and nationally tocommissioners and Public Health England.

• Staff were experienced and qualified to carry out their roles.Supervision occurred regularly and 100% of staff had receivedan appraisal in the year prior to our inspection. The serviceensured Disclosure and Barring Service checks were in placeand professional registration was checked for qualified staff.

• The service had built effective working relationships with localagencies. Staff undertook outreach work to promote equalityand human rights and to provide an inclusive and easilyaccessible service.


• Staff had not regularly reviewed the care and treatment needsof all clients. Of the 13 care records which were eligible to havea completed care plan, 62% had been completed and updated.The remainder were completed but not updated.

Are services caring?We do not currently rate standalone substance misuseservices.


• During our inspection we observed staff interactions withclients that were respectful and promoted choice and dignity.




• All clients we spoke to provided positive feedback about thecare they received. They felt valued and respected by caringand empathic staff. Clients felt staff provided a safe andsupportive service.

• Staff had an awareness of clients individual needs anddeveloped collaborative goals for recovery.

• Staff encouraged clients to maintain vocational andeducational roles and assisted them to undertake voluntarywork and access college courses.

• The service had a peer mentor scheme in place whichrecognised that people who had used the service previouslycould demonstrate to current clients that recovery wasachievable.


• The service had not carried out a client survey since becomingoperational in 2014. This had been recognised however andwas a key performance indicator identified for 2016-2017.

Are services responsive?We do not currently rate standalone substance misuseservices.


• Timescales for first interventions and follow upinterventions provided by the service were being met in linewith national guidance.

• The service had created local targets from referral toassessment to ensure new patients were seen and assessed ina timely manner. The service had met this target for 99% of newreferrals received between January and March 2016.

• The service was above the national average for achieving apositive closure for clients. A positive closure was identified aseither a client who had completed treatment and was alcoholfree, or had completed treatment and was now classified as anoccasional user of alcohol. The national average was 58%,Sandwell Alcohol service had achieved 72%.

• There were low numbers of clients re-presenting to the servicein the 12 months following a positive closure. The total for2015-2016 was 9, this represented less than 1% of the servicestotal caseload.




• Staff adhered to the service policy that outlined action to betaken when a client did not attend an appointment or made anunplanned exit from treatment. Staff offerred flexibleappointments and undertook outreach work in the localcommunity.

• The service had received 32 compliments in the 12 monthsprior to our inspection and one complaint. The provider hadinvestigated the complaint in line with their complaints policyand duty of candour was evident.

Are services well-led?We do not currently rate standalone substance misuseservices.


• The provider had set out a vision for its services and a set ofvalues for staff to work towards. Staff were aware of who seniormanagers were within the organisation and they had visited theservice recently.

• Managers undertook appraisals and supervision in line with theproviders policies and staff told us they felt supported in theirrole. Most staff were up to date with mandatory training and aplan was in place to increase training compliance.

• Governance systems were in place and the service producedlocal and national reports on its clinical effectiveness. Managersprovided feedback for staff following incidents and a learninglessons bulletin for staff was published every month.

• Morale amongst all staff was high. Staff that we metwith described a happy, supportive and collaborative ethos atthe service. Stakeholders and clients gave positive feedbackand described the service as supportive and client focussed.

• The service participated in improvement methodologies. Therewas evidence of multi agency collaborationincluding the development of the service to meet the diverseneeds of the local population.




Mental Capacity Act and Deprivation of Liberty Safeguards

• Mental Capacity Act training was provided for staff bySandwell Alcohol service. Although it was not part ofmandatory training, 86% of staff had attended this atthe time of our inspection.

• Staff obtained consent to treatment as part of the careplanning process and asked clients to sign informationsharing agreements to enable the service to liaise withother agencies. These were present in 16 of the 20 carerecords we reviewed.

• A policy was in place to provide guidance for staff onthe Mental Capacity Act and was available on theservice's intranet. Guidance on the use of the MentalCapacity Act was also available from the clinical leadnurse for the service or the provider's medical director.

Detailed findings from this inspection


Safe

EffectiveCaringResponsiveWell-led

Are substance misuse services safe?

Safe and clean environment:

• Staff used interview rooms fitted with panic alarmsto meet with clients, this meant that staff couldsummon assistance and support from colleagues ifrequired. All panic alarms were linked to a digital screenin the open plan working area shared by the SandwellAlcohol Service and the neighbouring drug treatmentservice (IRIS) for the Sandwell borough. The main alarmnotification screen in the office area provided the detailsof which room the alarm had been activated in andmeant that staff were able to respond without delay.Panic alarms were checked weekly to ensure they werefunctioning correctly and we reviewed records of this forthe previous six months which were complete.

• All client and staff communal and reception areas werevisibly clean and furniture was well maintained. All clientinterview rooms were visibly clean and tidy. All roomsand areas of the building were well lit with overheadlighting and natural light from windows. Client interviewrooms complied with risk management guidance(worker nearest the door) and there was an additional‘breakaway’ room with two exit doors should the workeror client wish to leave or be at risk.

• The clinic room in use by the service was well equipped,clean and tidy. The clinic room contained anexamination couch, weighing scales, sharps bins for thedisposal of needles and hand washing facilities. A fridgefor the storage of vaccinations was present and staff hadrecorded fridge temperatures twice daily for the pastthree months. All temperature checks were present andwere within the identified safe medicines storage rangeof two to eight degrees centigrade.

• Staff retained hazardous waste consignment notes infiles following the removal of clinical waste from theservice.

• Designated first aid responders were in place within theservice. Staff ensured a first aid box was present andcompleted a weekly contents check . Records of this forthe six months prior to our inspection were reviewedand found to be complete.

• Breathalysers were in use by the service and had beencalibrated in line with manufacturers recommendations.

• The building was leased to Sandwell Alcohol Service bythe local council who were responsible for themaintenance and cleaning of the building. Cleaningschedules were reviewed as part of our inspection andcontained a list of daily tasks which were complete andup to date. A meeting was held four times a year withthe local council facilities teamto review the on-goingsuitability of the premises or identify areas requiringwork.

• There were two fire marshals within the service, onemember of administrative staff and one other. The firewardens had high visibility jackets hung on the back oftheir office chairs to indicate who was responsible andtrained fire marshals names were listed throughout thebuilding as were designated first aiders. There were avariety of fire extinguishers throughout the building andall of them had been serviced until 2017. Theautomated fire prevention system had been checkedand a certificate of maintenance was reviewed and indate. The service completed a weekly check that firedoors were operational and the fire alarm was alsotested weekly. A fire drill was carried out with staff twiceyearly.

• Portable appliance testing of electrical items werecarried out annually with the most recent testcompleted in October 2015.

Substancemisuseservices

Substance misuse services


• An annual health and safety inspection report had beencompleted in October 2015. An annual health and safetyrisk assessment of the environment was completed inFebruary 2016.

• We observed staff adhering to infection controlprinciples including handwashing. There were alsoposters providing guidance on infection controltechniques on display in communal areas.

Safe staffing:

• At the time of our inspection there were 31 substantivestaff employed at Sandwell Alcohol Service. The seniorstaffing structure comprised a service manager who wasalso the registered manager for the service and threeteam leads. Each team lead line managed a mixture ofrecovery workers and substance misuse workers, as wellas taking a lead role within the service for eithersafeguarding or partnership working. A support workerwas also employed by the service and worked withclients with housing or financial difficulties.

• Two registered nurses were in post at the time of ourinspection, a clinical lead nurse who worked full timewithin the service and a nurse medical prescriber whoattended the service one day per week. The registerednurses provided clinical expertise for the monitoring ofclients undergoing community detoxificationprogrammes. They also provided physical healthmonitoring, the prescribing of anti-craving medicationand inoculation against blood borne viruses.

• Staffing vacancies at the time of our inspection were8%. The service manager identified that the teamstructure was in the process of being re-organised tomeet service need. There were no nursing vacanciesreported in the 12 months prior to our inspection andnursing assistants posts were not in place in the service.

• The staff sickness rates for the twelve month periodprior to inspection were 4%. During our inspection wediscussed this with the service manager who explainedthat sickness rates were due to three substantive staffwho had long term sickness absence. Two had sincereturned to work and one was no longer employed bythe service. As a result, sickness levels had decreasedduring the two months prior to inspection and werethree per cent in May 2016 and there were no recordedabsences in June 2016.

• The recorded turnover as a result of substantive staffleaving during the 12 month period prior to ourinspection was 24%. We discussed this with theregistered manager who explained that 24% wasequivalent to five staff. One of whom did not completetheir probationary period, one staff member left andsubsequently returned, one staff member was fixedterm cover for maternity leave and two staff had left forcareer progression after securing promotions.

• There had been no use of bank or agency staff in thethree months prior to our inspection. Staff told us thatshortage of staffing was rarely an issue and on theoccasions where extra staff were needed, they could bedrafted in from neighbouring services by the provider asrequired.

• The average caseload at the time of our inspection was31. This included recovery workers and substancemisuse workers. The support worker had a lowercaseload due to their role focussing on finances andhousing. Staff that we spoke with said that case loadswere reviewed regularly with team leaders duringsupervision and performance reviews. This wasdocumented within personnel files which we examinedas part of the inspection.

• There were no clients awaiting allocation to a workerfrom the Sandwell Alcohol Service at the time of ourinspection.

• The service operated a two stage duty rota to ensurethat there were sufficient staff in the event of sickness orunplanned absences. Two staff were allocated eitherthe duty worker or the back up duty worker role on adaily basis. Staff on duty were given protected time torespond to any crises that occurred, see clients that selfpresented to the service, or cover for staff sickness. Inthe event that the duty role was not used, allocated staffwere able to spend their time attending to case loaddocumentation. We saw this system in use during ourinspection of the service and staff that we spoke withreported that it worked effectively.

• A medical director for the Swanswell Alcohol service wasin post at the time of our inspection. They providedclinical leadership and supervision for the non-medicalprescriber and the clinical lead nurse based at Sandwell.

• Most staff were up to date with mandatory training andthe average compliance rate for attendance was 83%.




Staff had to complete certain training as part of theircore competencies in order to safely carry out their role.This included safeguarding, risk assessment, dataprotection and Mental Capacity Act training. Areas oftraining that were below a 75% attendance for staff werelone working and alcohol brief intervention training at70% and 40% respectively.

• Further training for staff was also offered by the localsafeguarding board on the "toxic trio" and safeguardingchildren and young people. The term "toxic trio" hasbeen used to describe the issues of domestic abuse,mental ill-health and substance misuse which havebeen identified as common features of families whereharm to children has occurred. They are viewed asindicators of increased risk of harm to children andyoung people.

Assessing and managing risk to patients and staff:

• During our inspection we reviewed 20 care records ofpeople that were using the service. All care recordscontained a completed and current risk assessment.Staff assessed risk during the client's initial assessmentand regularly reviewed and updated this. Riskassessments included a description of risk to others,risks of self harm, suicide, violence and history ofmedication abuse. All records also identified any currentor historical involvement with safeguarding services forchildren or adults.

• All risk assessments included the clients perspective ontheir risks and identified potential triggers that couldincrease risk. Staff and clients documentedindividualised symptoms within a risk managementplan that could help staff to identify when risk hadincreased for clients. Plans to manage risk involvedother key professionals where appropriate.

• There was no waiting list at the time of our inspection.Clients could present to the service at any time duringopening hours and be seen by the duty worker. Thisenabled staff to respond promptly to a suddendeterioration in the health of people using the service.

• The Care Quality Commission received no safeguardingconcern notifications from the service in the year priorto our inspection. Safeguarding training was availablefor staff and 100% of staff had attended this. Posters

were available for staff in the communal office areadetailing the process for making safeguarding referralsand included contact details for the local safeguardingteam.

• All clients referred to the service were screened forpotential safeguarding issues as part of the initial triageassessment. Staff completed electronic safeguardingreferral forms and those we spoke with knew how to usethis system and were confident in doing so. Staff at theservice had developed effective links with the localsafeguarding team who communicated daily with theservice via e-mail to check whether the service wereinvolved in new referrals that they had received. Staffwere also trained in the common assessmentframework. The common assessment framework is astandardised approach to conducting an assessment ofa child's additional needs and deciding how thoseneeds should be met.

• Staff had access to the Sandwell children's serviceelectronic system. This enabled them to check if caseswere open to this team and identify other professionalsinvolved in the care of the family. Staff would theninform the professional that they were also working withthe family for the purposes of information sharing andchild protection

• The service had taken part in a section 11 audit by theSandwell safeguarding children’s board in June of 2016.Section 11 of the Children’s Act 2004 places duties on arange of organisations and individuals to ensure theirfunctions, and any services that are contracted out toothers, are discharged having regard to the need tosafeguard and promote the welfare of children.Sandwell Alcohol Service were rated as 89% compliantwith their duties under section 11.

• Of the 20 care records reviewed, all had evidence ofappropriate identification and handling of safeguardingcases, although in one file the rationale behind notcontacting social services had not been recordedclearly. This was discussed with a team leader whoreviewed the case on the day of inspection,acknowledged it was not done well and advised theywould address it immediately.

• Staff followed the provider's lone working policy andprocedure when undertaking community visits. Staffwere required to complete their location on a




whiteboard in the central office and to call when startingand completing visits. Administrative staff documentsand monitored expected return times for staff . We sawthis system in use during our inspection and staffreported that it worked well. A safe word system wasalso in place for community staff when they called theoffice to request assistance if needed.

• During our inspection we reviewed the servicesprescribing policy, the prescribing procedure and theprescription administration procedure which were indate and had future revision dates identified. Theservice had a non-medical prescriber who worked oneday per week, with cover for annual leave provided bythe medical director. At the time of our inspection, theservice only prescribed anti craving medication forclients undergoing community detoxificationprogrammes, including campral and antabuse. Theclient's general practitioner completed physical healthscreenings prior to commencing communitydetoxification, with the service undertaking continuedphysical health monitoring of clients during thedetoxification.

• During our inspection we found that staff did not sign inor out keys used to access the prescription storage safe,meaning that prescription access could not be trackedeffectively. Staff did not fully complete documentationto evidence the tracking and reconciliation ofprescriptions . We also found that FP10MDA forms thathad been used for instalment prescribing of controlleddrugs were still held at the service, although they nolonger held the contract for opiate prescribing. Wenotified the registered manager and the non-medicalprescriber of our concerns on the day of our inspectionand they took immediate action to rectify the identifiedissues. This included the introduction of signing in andout sheets for the keys to the prescription safe, updatedprescription distribution and returns sheets and a newaudit and reconciliation procedure for prescriptions. AllFP10MDA prescription sheets were removed from theservice and disposed of and the void prescription recordform to document this was completed, signed andwitnessed.

• We reviewed five files for clients that had recentlystarted a community detoxification programme and sawevidence in all of them of collaborative work between

the service and the client's general practitioner. Ashared care agreement was also in place, which enabledthe service to continue prescribing for clients following adetoxification programme in the community.

• The service had a patient group directive policy in place.A patient group directive is an agreement signed by adoctor that can enable clinicians to supply oradminister prescription only medicines to clients.Clinicians can do this using their own assessment ofneed and without necessarily referring back to thedoctor for an individual prescription. At SandwellAlcohol Service, the use of a patient group directiveenabled the clinical lead nurse to carry out inoculationsfor Hepatitis B and provide the intramuscularadministration of Pabrinex. Pabrinex is a vitamin B and Cinjection used to correct a shortage of these vitaminsthat can occur as a result of alcohol abuse. Directionsfor the use of Pabrinex include special warnings of thepossibility of anaphylactic shock as a side effect andmakes recommendation that facilities for treatinganaphylactic reactions should be available wheneverPabrinex Intramuscular High Potency is administered.The clinical lead nurse that held the patient groupdirective for the administration of Pabrinex was aware ofthe reccomendations of its use and potential sideeffects. They had ensured that adrenaline was availablefor the treatment of anaphylaxis if needed.

Track record on safety:

• There were no serious incidents reported in the 12months prior to our inspection.

• Improvements in safety were evident within the service.Due to a high number of clients reporting suicidalideation or intent, suicide awareness training was madeavailable to staff and a suicidal ideation checklistintroduced as part of the risk assessment process. Staffalso held a meeting with the local mental health crisisteam in Sandwell to develop effective communicationlinks for dual diagnosis clients. Dual diagnosis clientsare those who have both alcohol and mental healthneeds.

• The service had identified that some clients were onlybeing referred to them whilst at the palliative stage oftheir care. Letters were sent out to all generalpractitioners in the borough highlighting this and askingthat all referrals for alcohol misuse issues be made at anearlier stage.




• The service had updated their agreement to treatmentform which clients completed during their initialassessment to include actions that the service wouldtake if they became aware that clients were drivingwhilst under the influence of alcohol. These changeswere a result of concerns raised about clients driving toappointments and potentially being above the nationaldrink drive safe recommended limits.

Reporting incidents and learning from when thingsgo wrong:

• All staff that we spoke with said they felt able to reportincidents and were aware of the process for doing so.Incident forms in use by the service had previously beenin a paper format, although the service was in theprocess of a transition to using an electronic risk recordsystem. The registered manager felt that the change toan electronic system would impove the services abiltyto audit reported incidents and identify trends for futurelearning.

• There had been 38 reported incidents during the 12months prior to our inspection. The highest reportedincidents were deaths of a client using the service at29% and clients reporting suicidal attempts or ideationat 26%. The registered manager maintained a record ofall reported incidents for the service and reported to theproviders governance team. A clinical qualityimplementation meeting was held monthly between theclinical quality team and all registered managers for theservice.

• During monthly clinical meetings, staff discussedfeedback from incidents internal to the service and aquarterly service wide lessons learnt bulletin wasavailable for all staff to review.

• Staff that we spoke with said that they felt wellsupported by team leaders and the services registeredmanager following incidents. The service had a protocolin place where team leaders met with staff to de brieffollowing incidents. Staff also had access to theprovider's employee support programme. This offeredstaff up to six complimentary sessions of counselling onan anonymous basis and an application for fundingcould be made for staff who required further supportafter this.

Duty of candour:

• Duty of candour was evident by the service in thehandling of the one complaint it had received in theprevious year. The service undertook a full investigation,acknowledged where their practice could be improvedand offered an apology to the people involved.

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

Assessment of needs and planning of care:

• During our inspection we reviewed 20 care records ofclients that were using the service. Of the 20 recordsreviewed, five clients had been with the service for lessthan one month and two had disengaged with theservice following the initial assessment process. Of theremaining 13 records that contained care plans, 62%had been completed and were in date and theremainder had been completed but not updated.

• Of the 13 completed care plans, 62% showed evidenceof personalisation by the client using the service. Stafftook a a holistic approach to client care and considereda range of needs in 85% of care records reviewed. In 76%of records reviewed staff had taken a recovery orientedapproach to care .

• Staff had completed information sharing agreements in80% of care records we reviewed. The informationsharing agreement was used for clients to documenttheir consent for the service to liaise with otheragencies, primarily their general practitioners to shareinformation regarding physical healthcare.

• In all care records staff had documented that they hadgiven harm reduction advice to clients and continuallyrevisited this throughout the clients treatment journey.

• Client records were kept in locked filing cabinets in alocked room on the upper floor of the building. The keysfor the cabinet were kept in a combination locked keycabinet by the filing cabinet and all staff had thecombination including administrative staff. Staff used anelectronic notes system, which was a web based secureaccess system. This meant that staff could access thenotes system remotely when working in communitylocations and were able to update and review carerecords and risk assessments in a timely manner. Staffscanned all paper records and letters of correspondence




from other agencies into the electronic notes systemand stored the original copy within the locked filingcabinets at the team base. Staff that we spoke with saidthat the system worked well and there had been noreported incidents of data loss in the 12 months prior toour inspection.

Best practice in treatment and care:

• Staff prescribed medication in line with the nationalinstitute for health and care excellence guidance onalcohol use disorders: diagnosis and management ofphysical health complications (CG100) and, thedepartment of health (UKCG07) drug misuse anddependence- guidelines on clinical management.Prescribing for clients undertaking communitydetoxification programmes was initiated by client'sgeneral practitioners. Follow up prescriptions foranti-craving medications and physical healthmonitoring was completed by the services non medicalprescriber nurse and clinical lead nurse.

• Staff were able to offer a range of psychosocialinterventions in line with national institute for healthand care excellence guidance for the diagnosis,assessment and management of harmful drinking andalcohol dependence (CG115). Interventions offered bystaff included motivational interviewing and solutionfocussed therapy. Motivational interviewing is agoal-oriented, client-centred counselling style foreliciting behaviour change by helping clients to exploreand resolve ambivalence towards change. Solutionfocussed therapy is a goal-directed collaborativeapproach to psychotherapeutic change that isconducted through direct observation of clients'responses to a series of questions. At the time of ourinspection, 70% of staff had been trained in deliveringthese interventions and care records indicated staffwere using these techniques with clients.

• A support worker was employed full time by the serviceto work with clients identified as experiencingdifficulties with debt management, benefits andhousing.

• Substance misuse workers assessed the physical healthneeds of clients during their initial assessment with theservice. Physical health monitoring was carried out bythe client’s general practitioner in the community. Wesaw evidence within care records of correspondence

with general practitioners to advise them that theirclient was receiving treatment and to requestinformation about medication or medical conditions.Staff sent follow up letters to the general practitioner atsix monthly intervals, or following any significant changein the clients treatment plan.

• Staff used outcome measures and rating scales tomeasure the severity of symptoms experience by clients.These included the patient health questionnaire for thesymptoms of depression and the generalised anxietydisorder assessment. Staff also completed thetreatment outcomes profile tool for clients at thebeginning of their treatment and when exiting theservice. The treatment outcome profile is the nationaloutcome monitoring tool for substance misuse services.

• The service completed quarterly service levelagreement reports for local commissioners and alsoparticipated in the national diagnostic outcomesmonitoring executive summary. This was a quarterlyreport on the service's effectiveness submitted to PublicHealth England.

• Team leaders completed case record audits on a regularbasis. Two full case file audits were completed permonth for each staff member. Team leaders looked atthe care plans and risk assessments, the managementof safeguarding concerns and screening for domesticabuse. The outcomes from case record audits formedpart of the staff supervision and appraisal process andwe saw evidence of this within personnel files.

Skilled staff to deliver care:

• Sandwell Alcohol Service was staffed by a range ofsubstance misuse workers, recovery workers and asupport worker. A clinical lead nurse was in post andworked at the service as a whole time equivalent and anon-medical prescriber attended the service one dayper week.

• Staff at the service were supported to undertake trainingto ensure they were appropriately qualified. Staff thatwere qualified were required to provide dates andevidence for continuing professional registration withthe nursing and midwifery council. The provider'shuman resources department monitored renewal datesfor professional registration and we were able to seeevidence of checks being carried out as part ofperformance reviews and appraisals.




• Disclosure barring checks were completed for all staff atthe commencement of their employment with theservice. A disclosure barring service procedure was inplace, in date and due for review in 2020. We reviewedthree personnel files during our inspection and all haddetails of completed Disclosure Barring Service checks.These were required to be renewed every three yearsand the provider's human resources department used atracker to monitor this .

• Training was available for staff to deliver psycho-socialinterventions, supporting people with mental healthproblems and suicidal awareness. The clinical leadnurse delivered training for staff in carrying out driedblood spot testing for blood borne viruses and a recordof all staff who had completed this training was kept inthe clinic room.

• The non-medical prescriber in post for the service was inthe process of completing their masters in advancedclinical practice and attended profession specificforums to maintain their clinical competencies.

• An induction policy for new staff was in place, had beenreviewed in 2015 and had a future revision date for setfor 2018. An induction procedure was used for staff thatwere new to the service and set expectations for eachstage of their six month probationary period. Staff saidthey had been well supported by team leaders duringtheir induction process and received regular reviews oftheir performance.

• Staff received regular supervision and all staff had anamed person to provide regular supervision for them.Supervision for staff was completed monthly and staffreported that they felt supported in their roles.Supervision for the non-medical prescriber and theclinical lead nurse was provided by the services medicaldirector and the clinical lead nurse also attended nursespecific group supervision on a monthly basis.

• At the time of our inspection, 100% of staff had receivedan appraisal within the previous 12 months.

• Staff performance was monitored though monthlysupervision sessions with team leaders. Where teamleaders identified poor staff performance , personnelfiles showed that they had highlighted the areas ofconcerns with staff and developed individualised actionplans with targets for improvement and agreed timescales.

Multi-disciplinary and inter agency team work:.

• Staff held a weekly team meeting and we attended thisas part of our inspection process. Items covered withinthis meeting included a review of previous minutes andactions, a review of policies and procedures, updates onprojects and outreach work and identification of futureareas for training.

• The registered manager held a fortnightly team leadersbusiness meeting and a monthly group clinical meeting.We reviewed minutes for the previous six months foreach of these meetings and saw that staff identifiedactions required for service improvement and set timescales for achievement.

• The registered manager attended a monthly clinicalgovernance implementation meeting with registeredmanagers from other services, the regional director forthe service and the medical director for the provider.

• Joint working between Sandwell Alcohol Service andthe criminal justice system and probationary servicestook place. The service worked with clients that hadbeen convicted of an alcohol related offence and hadbeen offered an alcohol treatment order requirement aspart of their sentence. In the period 1st January 2016 to31st March 2016, two alcohol treatment requirementshad been offered to clients using the service and sevenhad been completed.

• Stakeholders reported that the service had developedeffective working links with primary care and socialservices. A role had been developed for a hospitalliaison worker who visited the local hospital on a dailybasis and provided in-reach work for patients who hadbeen identified as having alcohol misuse issues. Theservice also provided clinics at local general practitionersurgeries and liver clinics at the local hospital outpatientdepartment.

• The registered manager for the service was part of theSandwell safety partnership board. This was amulti-agency arrangement with representation from thelocal police, ambulance service, fire service, probationservice and social services. The board was used toidentify areas where input from the alcohol service maybe required, such as attendance at local soup kitchensto engage with street drinkers.




Good practice in applying the Mental Capacity Act:

• Sandwell Alcohol Service provided Mental Capacity Acttraining and 86% of staff had attended this at the time ofour inspection.

• Staff obtained consent to treatment as part of the careplanning process and clients were also required to signinformation sharing agreements to enable the service toliaise with other agencies. These were present in 16 ofthe 20 care records we reviewed.

• A policy was in place to provide guidance for staff on theMental Capacity Act and was available for staff via theservice's intranet. Staff said that guidance on the use ofthe Mental Capacity Act could be obtained via theservice's medical director. Staff would also seek advicefrom colleagues they worked with in mental healthservices or the co-located substance misuse team.

Equality and human rights:

• The service had an Equality, Diversity and Human RightsPolicy in place. The purpose of which was to reflect theEquality Act 2010, provide guidance and standards toensure the individual needs of all service users were metand provide equal access to services.

• Accreditations held by the service as part of theircommitment to equitable access included: Investors inPeople, Leaders in Diversity, Stonewall DiversityChampions and Positive about disabled people.

• The service had identified that engaging Sikh andMuslim community members required a differentapproach because of the possible stigma surroundingalcohol misuse within their communities. The serviceprovided outreach work to local Sikh temples and aPunjabi speaking team member had provided alcoholawareness sessions on the Raaj local radio station.

• Swanswell provided substance misuse harm reductionand sexual health advice at Pride festival. Staffdistributed condoms, gave brief interventions advice,signposted to services and delivered specialist healthpromotion

• The service had identified that victims of domesticabuse might not feel safe to travel independently to theservice. Staff attended the women's refuges andprovided alcohol awareness advice and information andoffered one-to-one interventions to remove barriers toaccessing treatment.

Management of referral arrangements, transitionand discharge:

• Sandwell alcohol service received 1494 referrals duringthe period 1st April 2015 to 31st March 2016. The largestreferral source was from clients self referring into theservice and this accounted for 31% of the overall total.The two next largest referral sources were via generalpractitioner or local hospitals and these accounted for25% and 17% respectively. Referrals were also receivedfrom a variety of other sources including the job centre,probation services, social services and the prisonservice.

• There were 489 substance misuse service usersdischarged from the service in the 12 months period 1stApril 2015 to 31 March 2016. Clients were supported toaccess recovery services on discharge from Sandwellalcohol service and staff facilitated joint meetings withtheir client and the recovery service as part of thetransition and discharge process

• In the event of an unplanned exit from the service, staffwere able to use the information sharing agreement tonotify other agencies involved in their care. Thisincluded general practitioners and social services.

Are substance misuse services caring?

Kindness, dignity, respect and support:

• During our inspection we observed staff interactionswith clients that were respectful and promoted choiceand dignity. Clients that we spoke with described thestaff as providing practical and emotional support tothem during their recovery journey.

• As part of the inspection process, we attended a peersupport group facilitated by two staff and attended bysix clients. We also reviewed the feedback from 14comments cards that had been completed prior to ourinspection and interviewed a further two clients to gainan understanding of their experiences using the service.Without exception, all feedback we received about thecare provided by staff was extremely positive. Clientsdescribed the service as a safe and supportiveenvironment where they felt valued and respected by allstaff. Clients also described staff as caring andempathetic. One client described their key worker as“inspirational” and another described their key workeras their “rock”.




• Staff had an understanding of clients individual needs.Clients told us that staff took the time to understandtheir difficulties, and that they never felt rushed by staffduring appointments. Clients we spoke with said theyfelt that staff did not judge them if they didn’t manageto achieve the goals they had identified as part of thecare planning process.

• All clients that we spoke with said they felt that staffmaintained their privacy and confidentiality at all times.

The involvement of people in the care they receive:

• Clients reported they felt fully involved in the careprovided for them by the service. They were able to giveexamples of collaborative work with staff to set goals aspart of their recovery journey and told us that regularreviews of their progress took place. Staff routinelyoffered clients copies of their care plans and we wereable to see that signatures were available in careplanning documentation to evidence this.

• Staff encouraged clients to maintain theirindependence. Clients gave examples where staff hadsupported them to access public transport using anxietymanagement techniques and assisted them to gainvoluntary employment. One client provided feedbackthat they had been supported to attend a local collegeto improve numeracy and literary skills to help themachieve their ambition of obtaining a driving licence.

• A peer mentor scheme had been set up by the serviceand we were able to meet with a peer mentor as part ofour inspection process. The peer mentor schemerecognised that peer mentors who have used theservice previously added value to the service anddemonstrated to clients currently using the service thatrecovery was achievable. Peer mentors that worked withthe service were required to undergo Disclosure BarringService checks and received supervision from apermanent member of staff within the service.

• Advocacy services were available for clients to use ifrequired and were provided by the local council. We sawevidence within care records reviewed that staff haddiscussed access to advocacy with clients and therewere leaflets within the reception area which containeddetails for the advocacy service.

• Feedback leaflets were available for clients to completein the service's reception area. As part of the keyperformance indicators set out by local servicecommissioners, Sandwell alcohol service were planningto carry out a client survey in autumn 2016.

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

Access and discharge:

• The service worked towards the national target ofclients receiving first treatment interventions with awaiting time of three weeks or less. During the period1st January 2016 to 31st March 2016, 93% of all clientsreferred to Sandwell alcohol service met this target.Sandwell alcohol service achieved 100% against afurther target of three weeks from the first offeredintervention to subsequent follow up interventions .

• The service had agreed targets with commissioners fromreferral to assessment appointment which varieddepending on the needs of the client. The servicemonitored compliance with this target on a quarterlybasis. The target for referral to triage for clients that wereeither pregnant, involved with the criminal justicesystem or had been recently admitted to hospital was24 hours. During the period 1st January to 31st March2016 the service achieved a 100% compliance with thistarget.

• The target from referral to assessment for clients withparental responsibilities or clients with a significantmental or physical health need was 72 hrs. During theperiod 1st January to 31st March 2016 the serviceachieved a 99% compliance against this target. All otherreferrals to the service had a target from referral to triageof five days. During the period 1st January to 31st March2016 the service achieved a 98% compliance rateagainst this target.

• Sandwell Alcohol Service offered a total of 12225appointments for clients during the period of 1st April2015 to 31st March 2016. The total number ofappointments where clients did not attend was 2874 or24%. The service manager reported that this was adecrease from 32% during the same period for 2014 to2015.

• The national average for clients using alcohol servicesthat achieved a positive closure following interventionsoffered was 58%. A positive closure was identified aseither a client who had completed treatment and wasalcohol free, or had completed treatment and was now




classified as an occasional user of alcohol. For theperiod 1st April 2015 to 31st march 2016, the positiveclosure rate achieved by Sandwell alcohol service wasabove the national average at 72%.

• There were low numbers of clients re-presenting to theservice in the 12 months following their positive closureafter treatment and the total for the year 2015-2016 wasnine. This represented less than 1% of the service's totalcaseload.

• The team was able to respond promptly to clients if theypresented to the service in crisis. A two stage dutyworker rota system was in place. This enabled staff torespond to emergencies and cover unexpected staffabsence.

• The service had a did not attend policy in place toprovide guidance for staff when clients disengaged fromthe service. This included attempted follow up contactsbeing made by either phone, text or letter at least threetimes before a review was held prior to discharging theclient from the service. We saw evidence within casefiles of staff following the did not attend procedure.

• Clients that used the service told us that they wereoffered flexibility when choosing appointments. Theservice provided a 9am to 5pm service five days a week,with the opportunity for clients to book eveningappointments on a Thursday. A Saturday morningservice was run from 9am to 2pm and the service wasalso open during public holidays. Staff that we spokewith told us that they recognised the holiday seasonmay be the times when need for the service wasincreased and had planned the availability times tomeet this. The service also offered telephoneinterventions for clients that were unable to attend thelocation due to unforeseen circumstances.

• Clients that we spoke with said that appointments ranon time and we were not made aware of any occasionswhere client’s appointments had been cancelled.

The facilities promote comfort, dignity andrespect.

• Sandwell Alcohol Service had access to enough roomsacross two floors in order to see clients and had an

arrangement to share rooms with the adjoiningsubstance misuse team who shared the building. Ofthese rooms, two were meeting rooms large enough toconduct group work.

• Rooms were well labelled so it was clear to staff andclients which service was using them. Rooms were alsosound proofed to protect confidentiality.

• Information about the service was displayedand posters had been jointly designed and agreed byboth Sandwell Alcohol Service and the neighbouringsubstance misuse team. This was to maximise space inthe shared building and so as not to confuse clientswhere services offered similar services or information.There were two receptionists on the reception at alltimes, one from each service.

• Information leaflets were available for clients in thereception area, including guidance on providingfeedback on the service received and how to make acomplaint.

• There were leaflets and information available toclients on a range of local initiatives. These included thepeer support scheme run by the service and events runby local organisations including the West Midlands FireService and British Heart Foundation.

• Notices were available in reception informing clients oflocal drugs warnings. This included notifications of newtypes of substances in use in the area or an increase intheir strength.

Meeting the needs of all people who use theservice:

• There was access for people with reduced mobility atthe service. A lift was available for clients wishing toaccess the first floor and disabled access bathroomswere also available if required.

• Information leaflets were available in a range oflanguages and an interpreting service was available ifrequired. Staff members within the team also spoke arange of languages and were reflective of the localpopulation demographic.




Listening to and learning from concerns andcomplaints

• Clients that we spoke with said they were aware of theprovider's complaints procedure and felt confident touse it if required.

• The service had received 32 compliments in the 12months prior to our inspection and one complaintwhich had been partially upheld. We reviewed theservices management of this complaint as part of ourinspection. We saw that staff had investigated thecomplaint fully in line with the provider's policy andprocedure. The investigating staff member hadmaintained a comprehensive audit trail anddocumented all actions taken, this included meetingwith the complainant to explore the concerns raised. Anapology was made by the service to the complainantand details for the services medical director wereprovided.

• Staff identified lessons to be learnt resulting from thecomplaint and made operational recommendations toimprove practice and prevent a re-occurrence.

Are substance misuse services well-led?

Visions and Values:

• Staff were aware of the providers vision for the servicewhich was "to achieve a society free from problem drugand alcohol use". The provider also had a set of valuesin place which was for the service to be "honest,transparent, innovative, holistic and trustworthy". Staffwere able to give examples of how they demonstratedthe vision and values through their clinical practice.

• Staff knew who the senior strategic managers werewithin the service and reported that they were visibleand accessible. During our inspection we were able tomeet with the medical director and the regionaloperations manager.

Good governance:

• Most staff were up to date with mandatory training andthe average compliance rate for all staff across theservice was 83%. Staff also had access to additionaltraining to carry out their role, including motivationalinterviewing and assessment of the risk of domesticabuse.

• All staff had a nominated person within the service whoprovided supervision for them. We saw that supervisionof staff occurred frequently and was recorded inpersonnel files. Qualified staff were supervised by theprovider's medical director and were able to accessprofession specific group supervision and peer supportgroups. All staff in the service had received an annualappraisal in the twelve months prior to our inspection.

• All incidents that should be reported were reported andstaff were able to discuss how the provider's incidentreporting system worked. The service was in the processof transferring to a new electronic incident reportingsystem to improve their ability to audit reportedincidents and complete trend analysis.

• Staff were provided with feedback from incidents on aprovider wide basis through a quarterly lessons learnedbulletin. Complaints were investigated fully and in linewith the providers policies and procedures andrecommendations made to improve practice.

• There was evidence of effective links with localsafeguarding structures. A nominated safeguarding leadwas in place and attended regular meetings with thelocal multi-agency safeguarding hub.

• Mental Capacity Act training was available for staff and86% of staff had attended this. Staff showed awarenessof the need to consider clients mental capacity to makedecisions and knew where they could seek additionalsupport with using the Mental Capacity Act.

• The service submitted quarterly reports on theirperformance to local commissioners and keyperformance indicators were in place. The service alsosubmitted information to Public Health England usingthe national drug treatment monitoring system. Theservice had used performance reports to improve theirpractice. This included increasing the numbers of clientsengaged in treatment, increasing the number of positiveclosures and decreasing the numbers of clients that didnot attend appointments.

• The team manager felt they had sufficient authority tocarry out their role and spoke of being well supportedby staff within the service and senior strategicmanagement.

• The service had the ability to submit items to theprovider's risk register and we saw that the risk registerwas scored using a red, amber green system for levels of




risk. The provider identified mitigating control measuresas well as requirements for further risk mitigation. Therewere no items on the providers risk register relating tothe Sandwell service at the time of our inspection.

Leadership, morale and staff engagement:

• Sickness rates for the service in the year prior to ourinspection were low at 4%.

• At the time of our inspection there were no grievanceprocedures being pursued within the service, and therewere no allegations of bullying or harassment.

• All staff that we spoke with said that they felt able toraise concerns without fear of victimisation and felt theywould be supported to do so if required. Staff wereaware of the organisation's policy on raising concernsand were able to identify senior managers that theywould approach for support.

• Morale within the service was very good. Staff told usthey were well supported by their team leaders and theservices registered manager. Staff said that they enjoyedworking at the service and the team had an ethos ofworking together and helping each other when needed.A number of staff working at the service told us that theyloved their job, others said that it was a strong team,supportive and considerate.

• Staff told us they had the opportunity to becomeinvolved in projects outside of their core job role. Theyfelt able to seek advice on career progressionopportunities and contribute towards the developmentof the service. We saw that staff had developed theirroles to include outreach work in local temples andsoup kitchens. The service was also working with theNHS to develop physical health awareness with clients.

• Staff were open and transparent and explained toclients using the service if things went wrong. Theservice had received 32 compliments and onecomplaint in the 12 months prior to our inspection andwe reviewed this complaint during our visit. We saw thatthe service had acknowledged where mistakes hadbeen made, offered an apology and providedinformation for further support if required.

Commitment to quality improvement andinnovation:

• Sandwell alcohol service participated in the Blue Lightproject. The Blue Light project is Alcohol Concern’snational initiative to develop alternative approachesand care pathways for treatment resistant drinkers whoplace a burden on public services. It is supported byPublic Health England and 23 local authorities acrossthe country.




Areas for improvement

Action the provider SHOULD take to improve The provider should ensure that:

• Care plans are reviewed on a regular basis and thatthey are written in a language that demonstrates theinvolvement of clients.

• A client survey is commissioned to gain the views ofthe people who use the service.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


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