Archived: Lifeline Bradford Alcohol Service (Piccadilly Project)

We do not currently rate independent standalone substance misuse services.

We found the following areas of good practice:

• The service had addressed all but one action identified in the last inspection in relation to regulation 12 and 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014 and regulation 18 of the Health and Social Care Act (Registration) Regulation 2008.
• Bradford Piccadilly Project were assured of the safety of their building in relation to fire and gas safety. The service had an up to date gas safety check, and commissioned a new fire risk assessment. All actions had been undertaken within the correct time frames including the implementation of a Personal Emergency Evacuation Plan (PEEPs) policy.
• The service had implemented a new risk management tool to be aligned with the already existing risk assessment tool. We found staff were now completing risk management plans and scoring risk assessments according to guidance. Staff told us they felt the new risk management plans enabled them to identify and mitigate risk effectively. 
• All staff had received appraisals in the last 12 months.
• The service had notified the Care Quality Commission of two notifiable incidents in the last six months.
• The service implemented a risk register and regular annual audit cycle. The provider were now able to document how they assessed, monitored and mitigated risks relating to health, safety and welfare within the service.

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

• The service did not meet all the actions as a result of their last inspection. The service did not have systems in place to monitor compliance with supervision. The service implemented a system in place to monitor training; however, we found the data inputted onto the training matrix was not always correct. This meant management were not able to monitor compliance with training accurately. 

We do not currently rate independent standalone substance misuse services.

We found the following issues the provider needs to improve:

• The service did not respond to all the recommendations outlined by a fire risk assessment carried out in March 2015. The service was overdue a gas safety check by over one month. The last gas inspection was carried out in September 2015. This meant the provider was not assured of the safety of their premises.

• We found clients did not have risk management plans aligned to their risk assessments. In addition, staff did not always score risk assessments according the guidance provided. This meant staff could not be assured of the severity of risk to an individual and how to manage the risk towards the client and people within the service.

• The service did not routinely collect performance data relating to mandatory training. We did not see the service regularly reviewing appraisals and supervisions during team meetings or governance meetings. The service did not have systems in place which would ensure they could effectively assess, monitor or improved the quality and safety of the service.

However, we also found the following areas of good practice:

• We observed a team meeting and handover meeting which demonstrated good multi-disciplinary working, a supportive team ethic and an environment where staff could share practice and learning.

• All clients had up to date assessments including a newly modified ‘recovery action plan’. Staff were knowledgeable in delivering psychosocial interventions and had a holistic approach to caring for clients. They worked towards improving the clients’ recovery capital and moving them through the service without building dependency. There were a range of treatment programmes which clients could undergo were all underpinned by national guidelines. Staff worked closely with other agencies and could operate effectively in a multi-disciplinary fashion.

• We received very positive feedback about the service. Clients were happy with the quality of care their received. They commented on the responsiveness of the service and how they were able to support them. Clients felt staff were suitably qualified to care for them and offer the appropriate support.

• The service did not have any wait times for assessment and could provide clients with their first appointment within a week. The service had group rooms, therapy rooms and a lounge, which were clean, comfortable and well maintained. They were able to offer a service tailored to different communities within Bradford by offering programmes and literature in different languages. The service had upheld all its complaints and demonstrated a prompt response by implementing change in a timely manner.

• Staff demonstrated the spirit of the vision and values of the organisation. There was a strong team ethic and a positive morale. Staff were happy with local management and felt well supported in work.