• Community
  • Community substance misuse service

CGL Norfolk Alcohol and Drug Behavioural Change Service

Overall: Requires improvement read more about inspection ratings

Adobe House, 5 Barton Way, Norwich, Norfolk, NR1 1DL (01603) 514096

Provided and run by:
Change, Grow, Live

All Inspections

17 May 2022 to 9 June 2022

During an inspection looking at part of the service

Change Grow Live Norfolk Alcohol and Drug Behavioural Change Service is part of a national Change Grow Live provider who provide a not-for-profit drug and alcohol treatment service. The Norfolk location has been delivering a service since April 2018.

We carried out an unannounced focussed visit to Change Grow Live Norwich on 17 May 2022 and an announced visit on 9 June 2022.

The aim of this focussed inspection was to review the breaches in regulation identified following our most recent inspection in October 2021, which were contained in the warning notice. These breaches identified under the safe, effective and well-led domains.

During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate in the Well led key question. As a result of this, the imposed conditions have now been removed. The requires improvement ratings for Safe and Effective key questions remain unchanged. Our rating of this location stayed the same. We rated it as requires improvement because:

  • Since the previous inspection there had been improvements made to the governance structure and an action plan had been implemented to address the issues found at the previous inspection. However, whilst we saw improved mechanisms for capturing and monitoring information had been introduced, actions had not always been taken as a result.
  • Managers had not always ensured that drug testing had taken place in line with the service’s policy. Staff had missed opportunities to resolve this issue at face-to-face appointments.
  • Managers had not ensured that clients always had timely access to medical reviews.
  • Managers had not ensured that all staff had access to supervision.

However:

  • Staff had ensured that clinical environment and equipment audits had been completed and were up to date.
  • Service user plans reviewed were comprehensive, personalised, holistic and recovery orientated.
  • Staff had completed comprehensive risk assessments and updated these regularly.
  • Managers ensured staff were up to date with appraisals.

5 & 6th October 2021

During an inspection looking at part of the service

Our rating of this location stayed the same. We rated it as requires improvement because:

The service did not always provide safe care. Risk assessments had not always reflected accurately the current risks and there was a lack of contingency plans in place to mitigate identified risks. The number of out of date risk assessments was 27% at the time of inspection.

Staff had not always developed holistic, recovery-oriented care plans and did not always reflect the range of interventions available.

The service did not ensure that urine drug testing was undertaken regularly with clients when required.

Staff had high caseloads which meant they were unable to maintain full oversight of all their clients’ needs and were not always able to respond in a timely way.

Nursing staff had not completed weekly checks of medical equipment on site and the EpiPen dosage in the emergency bag did not have the correct adult dosage which had not been identified as a concern.

The correct monitoring of prescribing reviews according to CGLs own policy had only recently been implemented despite the process changing six months previously.

Not all incidents were reviewed and closed within the correct timeframes stated within CGL policy.

Not all staff were receiving regular appraisals in line with CGL policy.

Governance processes did not identify all the concerns addressed within this report. This meant that managers did not have sufficient oversight to be assured that systems and processes were robust and effective. Where managers had identified concerns, action taken had not resulted in improvement.

However:

Staff worked hard and demonstrated compassion and kindness toward clients they supported.

Feedback from clients and carers was consistently positive about staff attitudes and their approach to care.

All clients had a named recovery co-ordinator who acted as a point of contact for the service.

The service offered a wide range of interventions including substance specific recovery groups, specialist interest groups and carers support groups. During Covid-19 lockdown restrictions the service had adapted their delivery by supporting clients to access online teleconferencing and providing some clients with mobile phones.

The service worked collaboratively with partner agencies and had successfully launched new initiatives to improve the outcomes for clients. For example, the service had trained police staff in how to administer naloxone to reverse the effects of overdosing and had also launched Project ADDER (Addiction, Diversion, Disruption, Enforcement and Recovery) which consisted of a multi-agency criminal justice team to help support clients involved with drug and crime related activity.

09 -12 July 2019

During a routine inspection

We rated CGL Norfolk as requires improvement overall because:

  • Information relating to the safety of clients was not always comprehensive or timely. During the inspection we found risk assessments for clients that were out of date and not reviewed following an incident. Not all records contained GP summaries and there was a lack of crisis plans throughout. Care plans lacked detail. Overarching recovery goals were not routinely documented and did not reflect discussions held with the client. There was a lack of discharge planning and clients’ plans did not always address the potential risks of early exit from the programme.
  • The service did not keep a safeguarding log. Therefore, managers were not able to review outcomes and did not have oversight of reporting.
  • Staff compliance with basic life support skills was 19%.
  • Staff had not received an annual appraisal of their work performance.
  • We found some incidents reported had passed the timeframe for review by managers of the service.
  • The provider did not always have governance systems in place to effectively manage the service. Governance policies, procedures and protocols were regularly reviewed and improved to ensure the service delivered safe, good quality interventions in line with national best practice. however, these were not fully embedded.

However:

  • The service had robust health and safety systems in place to manage the safety of the environment. All areas at the services were clean and well maintained. Clinic rooms, testing rooms and needle exchanges were well stocked and were kept locked when not in use.
  • Staff held daily flash meetings where all staff engaged in detailed discussion of client risks. Where appropriate these risks were shared with relevant stakeholders. Staff worked effectively within teams, across services and with other agencies to promote safety including systems and practices in information sharing.
  • Staff completed an initial assessment for clients in a timely manner and the care plan identified the person's recovery worker. The service ensured multidisciplinary input into people's initial assessments and staff provided a range of care and treatment interventions suitable for the client group.
  • Staff were open and welcoming to all who attended. Clients were able to drop in to the service and staff would see them. Staff would offer responsive and emotional support. Staff talked about clients with compassion and respect.
  • Clients we spoke with told us that staff were always available and they received positive support. Clients felt safe and said that staff were caring and welcoming. Staff enabled families and carers to give feedback on the service they received.
  • The service was able to see clients who were urgently referred quickly. There was a system in place to ensure priority cases were given the earliest appointment available. Those people discharged from hospital were also made a priority and seen quickly. The service had alternative care pathways and referral systems in place for people whose needs could not be met by the service.
  • Staff demonstrated an understanding of the potential issues facing vulnerable groups. Staff at the service promoted equality and diversity, this included lesbian gay bisexual transgender+ and black and minority ethnic groups. Staff were passionate in this area and were involved in events in the local community to support this.
  • Leaders at the service had the skills, knowledge and experience to perform their roles, and provided leadership to their staff.  The organisation had a clear definition of recovery and this was understood by all staff. Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing.