15 and 16 November 2022
During a routine inspection
Our rating of this service improved. We rated it as good because:
- Clients, family carers and employed carers we spoke with gave very positive feedback about the service. They described caring and professional staff often going above and beyond their expectations. They were particularly positive about the aquatherapy sessions provided. Supported living services were very positive about the service provided to clients, and support and training provided to staff teams.
- Significant improvements had been made since the previous inspection in May 2021 particularly to the governance of the service. There was an improved system for monitoring staff compliance with mandatory training. Improvements had been made in the service’s risk management systems, and monitoring, and evaluation of the team’s performance. The team had developed a clear protocol for following up on clients who missed appointments, an improved system to collect feedback from clients and stakeholders, and staff were clear about which incidents should be notified to the CQC.
- There were systems in place to share any lessons learned from incidents, complaints, concerns and safeguarding, although there had been very few incidents and no complaints in the last year. All staff and managers were clear about how to navigate and review clients’ care and treatment records and staff knew where to store them.
- There had been some improvements in the referral process to the service, making it easier for clinicians to make referrals through a single point of access. The criteria for referral to the service did not exclude clients who would have benefitted from care.
- The number of clients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each client the time they needed.
- Staff understood how to protect clients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. Staff followed good practice with respect to safeguarding.
- Staff provided a range of treatment and care for clients that was informed by best-practice guidance and suitable to the needs of the clients. They ensured that clients had good access to physical healthcare and supported them to live healthier lives. Staff developed treatment plans in collaboration with clients, families and carers.
- The teams included or had access to the full range of specialists required to meet the needs of the clients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
- Staff felt respected, supported and valued. They said the provider promoted equality and diversity in daily work and provided opportunities for development and career progression. They could raise any concerns without fear.
However:
- There were insufficiently rigorous systems in place to record individual risks for clients using the service, and review these regularly.
- Improvements were needed in infection control procedures for the service to ensure that there were clear protocols for storing and laundering hoist slings, and reviewing staff compliance with infection control protocols.
- Staff did not have training in basic life support, to support clients in the event of an emergency.
- The service notice board at the Sutton Inclusion Centre, was not easily accessible to clients and carers, and there were no leaflets available in reception about health issues for clients/carers to access. The service did not routinely share how feedback from clients and carers was used to improve the service
- Although decisions made in clients’ best interests were recorded, these were not always dated.
- The auditing of service delivery could be further developed.