28-30 January 2019
During a routine inspection
We rated Calderdale Recovery Steps as good because:
- The safety of the service, including that of clients, staff and the environment, was managed well. Incidents were reported, reviewed and learning shared within the service and across the partnership.
- Staff understood their roles and responsibilities in safeguarding adults and children at risk and carried these out.
- The multi-disciplinary team provided assessment, care and treatment to clients in line with best practice and national guidelines. Staff were skilled and knowledgeable in their roles and had opportunities for further development. The service monitored closely their performance and outcomes for clients were in line with the national average. The provider had retained accreditation for investors in volunteers.
- Staff were caring and professional. Feedback from clients and carers was positive, particularly in relation to the range of interventions available and the impact this had on peoples lives.
- The service took a proactive approach to understanding the needs of different groups of people and delivered care in a way that met these needs and promoted equality. Access to the service was timely and staff were committed to maximising client attendance and commitment to their recovery journey, through a flexible and non-punitive approach. The service ensured clients and carers could make a complaint and was responsive to feedback. The provider retained its Equality Gold Standard award in 2018.
- The service was well led. Managers were skilled, knowledgeable and experienced. The culture within the service ensured staff felt respected, valued and supported by leaders. Staff morale was high. The service had effective systems and processes in assessing, monitoring and improving the quality and safety of the service. Managers had identified areas for improvement and had plans in place to address these. Leaders supported the development of staff and fostered a culture of continuous improvement and innovation. Managers at all levels understood the challenges within the service and the treatment population and were driven to achieve better outcomes.
However:
- The service did not assess the capacity of a client in a timely way when concerns were identified in relation to capacity to consent to treatment.
- Cleaning records were not completed, and the infection control and fire audits did not demonstrate that the actions had been completed.
- Care records did not always clearly reflect individual recovery goals or the extent of client involvement into the development of care plans.