DISC (Developing Initiatives Supporting Communities ... · Howwecarriedoutthisinspection Tounderstandtheexperienceofpeoplewhouse services,weaskthefollowingfivequestionsaboutevery

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.

We found the following issues that the service providerneeds to improve:

• Staff did not always maintain the dignity and privacyof client’s during treatment in clinic rooms at IrfordHouse and two clinic rooms at Armley Park Court.Staff told us that clients would on occasion need topartially undress for physical health examinations,

including electrocardiogram monitoring. There wereno privacy screens around examination couches inthese rooms and the glass panels in the doors werenot obscured.

• Staff at Forward Leeds did not always receive aninduction into their role and as such did not have thenecessary skills and training to ensure their ownsafety and that of the people using the service. Staffattendance at mandatory training was lowin Forward Leeds and compliance with local

DeDevelopingveloping InitiativesInitiatives ffororSupportSupport inin thethe CommunityCommunityQuality Report

Horndale AvenueAycliffe Business ParkNewton AycliffeCounty DurhamDL5 6DSTel:01325 731160Website: www.disc-vol.org.uk

Date of inspection visit: 5 December 2016 to 8December 2016Date of publication: 24/03/2017

1 Developing Initiatives for Support in the Community Quality Report 24/03/2017

mandatory training was low in Calderdale RecoverySteps. Developing Initiatives for Support in theCommunity did not have effective systems in placeto monitor this.

• The provider did not have a system or processestablished to monitor compliance with the MentalCapacity Act 2005. Staff understanding of theirresponsibilities under the Act varied and they takenot take a consistent approach to assessing clients’capacity.

• At Forward Leeds, staff did not always ensure thatrisk assessments contained all identified risks foreach client and did not always develop a clear planto manage those risks. They did not always reviewrisk at the frequency defined by national guidanceand the provider's policy.

• Recovery plans at Forward Leeds were not alwayspersonalised and reviewed as required. Recoveryplans at Calderdale Recovery Steps did not alwayscontain sufficient detail, or the client's views.

• Developing Initiatives for Support in theCommunity did not always ensure that systems andprocesses were operating effectively in ForwardLeeds, where they were the lead contract holder. Thisled to issues with infection control procedures,emergency medicines and the management ofclinical waste.

• We found equipment at the Kirkgate hub that wasunclean.

However, we also found the following areas of goodpractice:

• The majority of feedback from clients and theircarers was very positive about theservices Developing Initiatives for Support in theCommunity provided. Clients and carers reportedstaff were kind and respectful and involved them indecisions about their care and treatment.

• Staff used evidence based assessment tools tomeasure clients’ substance misuse and emotionalwellbeing. Developing Initiatives for Support in theCommunity offered access to treatmentrecommended by national guidance, depending onthe needs of each client.

• Developing Initiatives for Support in the Communityencouraged clients to become peer mentors tosupport others in the early stages of treatment.Clients were able to attend service user forums andprovide feedback on the service to inform itsdevelopment and delivery. Developing Initiatives forSupport in the Community had developed aRecovery Academy in Leeds, which offered a widerange of recovery focused activities and structuredgroup work. Recovery Support was also available atCalderdale Recovery Steps and North YorkshireHorizons.

• Developing Initiatives for Support in the Communitytook into account the diverse needs of the clientgroup and made a number of adaptations to theirservices to ensure they were accessible to all. Staffworked with vulnerable and heard to reach groups tosupport them to access services. DevelopingInitiatives for Support in the Community had heldthe Equality North East ‘Equality Standard GoldAward’ since 2012.

• Developing Initiatives for Support in the Communitywere committed to quality improvement andinnovation, which involved the use of externalstandards and frameworks. Developing Initiatives forSupport in the Community had been awarded theInvestors in People silver award in August 2016 andhad an action plan in place to work towards goldstandard.

• Staff felt valued by the organisation and stated thatthey were able to input into the delivery of services.Staff were passionate about the work they did andmost reported good morale and relationships withintheir teams.

Summary of findings


Contents

PageSummary of this inspectionBackground to Developing Initiatives for Support in the Community 5

Our inspection team 6

Why we carried out this inspection 6

How we carried out this inspection 7

What people who use the service say 7

The five questions we ask about services and what we found 9

Detailed findings from this inspectionMental Capacity Act and Deprivation of Liberty Safeguards 14

Outstanding practice 42

Areas for improvement 42

Action we have told the provider to take 44

Summary of findings


Developing Initiatives forSupport in the Community

Services we looked at:Substance misuse services

DevelopingInitiativesforSupportintheCommunity


Background to Developing Initiatives for Support in the Community

Developing Initiatives for Support in the Community is aregistered charity founded in 1984, which providesspecialist substance misuse services across the NorthEast, Yorkshire, Humber and the North West ofEngland. Developing Initiatives for Support in theCommunity offers the following services for clients:

• Recovery services for drug and alcohol

• Health, young people and families

• Skills, employment and training

• Developing Initiatives for Support in the Communityhousing

• Independent living

• Promotion of volunteering and employmentopportunities through ‘More Time’ social enterprise

This inspection focused only on the recovery services fordrug and alcohol as this is the only part registered withthe CQC for the provision of regulated activities.Developing Initiatives for Support in the Community hasone registered location with the CQC, which is theorganisation’s head office. The registered manager hadrecently retired and a temporary registered manager wasin place at the time of inspection.

This service is registered by CQC to provide the followingregulated activities:

• Caring for adults over 65 years

• Caring for children (0 – 18 years)

• Services for everyone

• Treatment of disease, disorder or injury

Developing Initiatives for Support in the Community hasfour drug and alcohol service delivery units, whichoperate from different hubs as follows:

Forward Leeds

• Kirkgate

• Irford

• Armley

Calderdale Recovery Steps

• Halifax

• Todmorden

North Yorkshire Horizons

• Northallerton

• Selby

• Skipton

• Scarborough

• Harrogate

Sunderland Wear Recovery

• Sunderland (needle exchange only)

The services are commissioned by Sunderland CityCouncil, Leeds City Council, North Yorkshire Council andCalderdale Council. Developing Initiatives for Support inthe Community work in partnership with other providersin these areas. Developing Initiatives for Support in theCommunity are the lead provider in Forward Leeds,Calderdale Recovery Steps and North YorkshireHorizons.

As part of this inspection, we visited the following hubs toinspect the recovery services for drug and alcohol:

Halifax - Calderdale Recovery Steps

Armley - Forward Leeds

Irford - Forward Leeds

Kirkgate - Forward Leeds

Harrogate - North Yorkshire Horizons

Scarborough – North Yorkshire Horizons

Sapphire House – head office

Forward Leeds is the second largest substance misuseservice in the country. Developing Initiatives for Supportin the Community subcontracts to four other providers inthe Forward Leeds consortium. Each provider in theconsortium delivers a component of the substancemisuse contract. One service delivers assertive outreach

Summaryofthisinspection

Summary of this inspection


interventions and brief interventions, another deliversclinical interventions for opiate and alcohol dependency,another delivers specialist clinical interventions forpregnant women and dual diagnosis and anotherdelivers family interventions. Forward Leeds alsoprovides a young people’s service.

Calderdale Recovery Steps is a partnership of threeproviders which deliver accessible adult drug and alcoholservices across Calderdale. The project focuses onrecovery, harm reduction and user involvement. Theservice offers bespoke treatments for individuals. Clientsmay use local ‘Recovery Hubs’ in Halifax or ruralTodmorden, or go to their own GP surgeries fortreatment, support and reviews known as primary careextended services. The programme is designed to offerseamless, accessible, and relevant services, which willenable service users to work towards recovery.

Developing Initiatives for Support in theCommunity works in partnership with four otherproviders under the umbrella of North Yorkshire Horizons.North Yorkshire Horizons provides support to enable asmany people as possible to recover from drug andalcohol dependency in North Yorkshire. The service aimsto reduce the harms caused by drug and alcohol misuseto both individuals and communities. Local access inrural areas is provided via community venues.

We have previously inspected Developing Initiatives forSupport in the Community once, in January 2014. At thattime, the provider was found to be meeting all requiredstandards. This is the first inspection by the CQC underthe current methodology.

Our inspection team

Due to the size and complexity of this inspection,different teams inspected different parts of the service.We also inspected another provider at the same time, asboth worked together in both the Forward Leeds andCalderdale Recovery Steps services. Inspectors hadclearly defined roles about who was leading on whichpart of the inspection, with separate inspectors taking thelead for each provider at both Forward Leeds andCalderdale Recovery Steps. A separate report is beingwritten for the other provider.

The team who inspected Forward Leeds comprised aninspection manager, Kate Gorse-Brightmore (leadinspector), four inspectors, an assistant inspector, abusiness support officer and one substance misuse nursecurrently working in the substance misuse field.

The team who inspected Calderdale Recovery Stepscomprised two inspectors, with Joanne White as the leadinspector and one substance misuse nurse currentlyworking in the substance misuse field.

The team who inspected North Yorkshire Horizonscomprised two inspectors. Pauline O'Rourke was the leadinspector for the Scarborough hub and Jacqueline Bondwas the lead inspector for the Northallerton hub.

The team who inspected Sapphire House comprised oneinspection manager and two inspectors. Jayne Lightfootwas the lead inspector and author of this report, whichcombined all of the inspection activity detailed above.

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 needs

• is it well led?

Before the inspection visit, we reviewed information thatwe held about the location and asked otherorganisations for feedback.

During the inspection visit, the inspection team:

• visited seven hubs and looked at the quality of thephysical environment

• observed six individual appointments with clients,four group sessions, an enhanced shared careservice appointment and a co-production meeting atthe Recovery Chapel

• spoke with 26 clients

• spoke with 11 carers whose relatives or friendsaccessed support from the service

• spoke with the registered manager, chief executiveofficer, quality manager, human resources manager,

operations director at Forward Leeds and CalderdaleRecovery Steps, area manager at North YorkshireHorizons, assistant director at Calderdale RecoverySteps and the team managers at each of the six hubsvisited

• spoke with 44 other staff members employed by theservice, including recovery co-coordinators,administrative staff and volunteers

• spoke with 19 staff members who worked in theForward Leeds service but were employed by adifferent service provider

• spoke with six peer mentors and four volunteers

• observed three staff meetings and a partnershipboard meeting

• collected feedback from 81 comment cards

• looked at 62 care and treatment records for clients

• received feedback about the service from sixstakeholders including partner agencies andcommissioners

• reviewed 15 staff supervision files, one probationaryreview and six staff appraisals

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

What people who use the service say

Of the 37 comment cards at Forward Leeds, there weretwo negative comments, nine had mixed reviews and theremaining 26 were positive. Clients, relatives and carerswe spoke to during the inspection were also positiveoverall about the service they received and the approachfrom all Forward Leeds staff. Clients reported that staffwere respectful, helpful, and polite. Clients told us thatthey had their treatment options explained to them, andthey were involved in decisions about their care.However, four comment cards gave feedback that therewere not sufficient appointments, that they ran late andthat clients were passed around from worker to worker.

During the inspection, staff had to cancel an appointmentand one carer commented that was the second time thishad happened. A review of complaints received byForward Leeds in the 12 months prior to the inspectionshowed that 34 of 287 complaints were regarding late,cancelled or rescheduled appointments by the service.

All feedback received from clients and carers at NorthYorkshire Horizons was positive about the service theyand their relative received. Comments included that staffwere non-judgemental and never gave up on them andthat the service they received was excellent. One persontold us that a recent stay in hospital had been made




easier because of the Developing Initiatives for Support inthe Community hospital liaison worker who was able tocontact different agencies and speak with hospital staff tohelp the client understand what was going on. A carertold us it was good only having to worry about speakingwith one person rather than several. One carercommented how they would like the opportunity for theirown appointment with the worker to help support themto look after their relative.

The majority of carers spoke positively of the supportboth they and their relative or friend received from theservice. They reported good access to staff and open lines

of communication. Carers felt staff involved them in thecare and treatment of the client to ensure they hadon-going support outside of appointments. One carerreported that staff tailored their approach to take intoaccount the additional needs of their relative andensured the level of support provided was at the rightpace for the client.

All feedback received from six stakeholders, includingpartner agencies and commissioners, was positive aboutthe care and treatment provided by Developing Initiativesfor Support in the Community.




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.

We found the following issues that the service provider needsto improve:

• At Forward Leeds, staff did not always provide sufficient detailin risk management plans to evidence how risk was beingmanaged. Risk management plans did not always contain allidentified risks for that client and were not always reviewed inline with national guidance and their own policy. Managerswere aware of these issues and had plans in place to addressthem, including further staff training. Risk assessments and riskmanagement plans were detailed and generally up to date inNorth Yorkshire Horizons and Calderdale Recovery Steps.

• Forward Leeds did not have a policy in place to manage therisks presented when children attended the hubs. We observedchildren in busy reception areas at all three hubs and staff didnot take a consistent approach to ensuring their safety.

• Although most hubs were visibly clean, we found uncleanequipment at the Kirkgate hub. This equipment wasnot included on the cleaning schedules.

• At Armley Park Court hub and Irford House hub, infectioncontrol principles were not always adhered to. Across ForwardLeeds and Calderdale Recovery Steps, compliance withmandatory training in infection control was low. The testingrooms at the Kirkgate hub were not fully stocked with apronsand gloves. Hot water checks were not up to date at the IrfordHouse hub as required in the legionella risk assessment. Staffdid not always adhere to guidance on the storage andmanagement of clinical waste.

• At Armley Park Court hub, one of the emergency medicines wasout of date. Managers rectified this during our visit.

• Compliance with mandatory training was low for some coursesin the Forward Leeds service and the Halifax hub of theCalderdale Recovery Steps service.

• Some clinic equipment was shared between the clinic rooms inthe hubs in Forward Leeds, such as breathalysers and bloodpressure monitors. This meant that staff did not always haveaccess to equipment at the time it was needed.

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




• The North Yorkshire Horizons services were rolling outadditional safeguarding children training and home visittraining to all new staff that were being recruited. They alsoworked closely with the family drug and alcohol courts tosupport clients to understand the impact of substance misuseon children.

• Staff could identify the different types of abuse and knew howto make safeguarding referrals.

• Developing Initiatives for Support in theCommunity's recruitment and selection policies andprocedures supported the safe recruitment of staff.

• Developing Initiatives for Support in the Community hadeffective systems and processes in place to report and monitorincidents. Staff could provide examples of lessons learnedwhen things went wrong and improvements made followingincidents.

.

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


• Compliance with induction training was low at the ForwardLeeds hubs. This meant that staff had not received thenecessary training to ensure their own safety and that of peopleusing the service.

• At Forward Leeds and Calderdale Recovery Steps, staff did notalways provide sufficient detail in client’s recovery plans. Theywere not always personalised or recovery orientated. Staff atForward Leeds did not always review recovery plans every 12weeks, in line with national guidance and their own policy.

• Developing Initiatives for Support in the Community did nothave a system or process established, to assess and monitorstaff compliance with the Mental Capacity Act 2005.


• Developing Initiatives for Support in the Community deliveredcare and treatment in line with national guidance and bestpractice. Staff attended practice development groups to ensurethey kept up to date with current guidance. Staff used evidencebased assessment tools to measure clients’ substance misuseand emotional wellbeing.




• Staff received quarterly supervision and annual appraisals inline with the provider's policy.

• Developing Initiatives for Support in the Community worked inpartnership with other providers to deliver substance misuseservices to clients. Staff also worked closely with other servicesand agencies to support the care and treatment of clients.

• Staff worked with vulnerable and hard to reach groups toensure they could access services. Developing Initiatives forSupport in the Community had held the Equality North East‘Equality Standard Gold Award’ since 2012.

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

We found the following areas of good practice:

• The majority of feedback from clients and their carers was verypositive about the services provided. Clients and carersreported staff treated them with respect, werenon-judgemental, kind and polite.

• We observed positive interactions between staff and clients,with staff detailing all the treatment options available andtaking into account the client’s views. Carers reported staffinvolved them in the clients care and treatment.

• Developing Initiatives for Support in the Community had aservice user involvement and engagement policy and serviceuser forums were held at each hub. We could see examples ofchanges to service delivery following feedback through theseforums. Developing Initiatives for Support in the Communityalso encouraged clients to become peer mentors to supportothers in the early stages of their treatment journey.

• Developing Initiatives for Support in the Community haddeveloped a Recovery Academy in Leeds, which was a place forclients who were in recovery and offered a wide range ofrecovery focussed activities and structured group work. Staffmanaged the Recovery Academy and the sessions deliveredwere co-produced with people with lived experience ofsubstance misuse. Recovery Support was also available atCalderdale Recovery Steps and North Yorkshire Horizons.

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





• There were glass panels on the doors of some clinic rooms atForward Leeds that were not obscured. Staff could not alwaysmaintain the privacy and dignity of clients being treated inthese rooms.

• Although waiting times for access to treatment were generallygood, we saw two examples where there was a delay betweenassessment and the start of treatment with a recoveryco-ordinator in Forward Leeds. There were no concerns aboutwaiting times at the other services.

• Staff in the Halifax hub of Calderdale Recovery Steps were notaccurately recording appointment cancellations, which made itdifficult for Developing Initiatives for Support in the Communityto accurately monitor the number of appointments beingcancelled by the service. This was raised during the inspectionand the provider identified that further staff training on theelectronic system was required. Clients told us that the servicedid not always communicate appointment cancellations in atimely manner.


• Developing Initiatives for Support in the Community providedgood access to services, with clients able to drop into any of thehubs or be referred by their GP or another professional. All hubsoperated a single point of contact to ensure ease of access. Allhubs provided a late night opening for clients who could notattended during the day.

• All hubs had sufficient rooms to deliver care and treatment,including group-work rooms, one to one rooms and clinicrooms.

• Developing Initiatives for Support in the Community hadadapted their service delivery to respond to the 2016 NHSAccessible Information standards. The provider also ensuredtheir websites were accessible for people with dyslexia, readingdifficulties and visual impairments. Developing Initiatives forSupport in the Community provided the use of telephonebased interpreting services and their publicity materials andinformation for clients was published in multiple languages.

• Forward Leeds was performing better than the national averagefor clients starting treatment interventions within three weeks.Calderdale Recovery Steps had seen an increase in bothalcohol and drug clients successfully completing treatment.

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





• In Forward Leeds, where Developing Initiatives for Support inthe Community was the lead contract holder, they did notalways ensure all systems and processes were effective todeliver a safe service.


• We observed staff in all roles demonstrating the current valuesin their approach with clients. Developing Initiatives for Supportin the Community were reviewing their mission, vision andvalues at the time of inspection through consultation with staffand clients.

• Developing Initiatives for Support in the Community hadestablished processes with other providers and commissionersfor monitoring performance within each service. Staffcompleted weekly and fortnightly performance reports whichwere cascaded to management and staff teams. DevelopingInitiatives for Support in the Community used performancemonitoring to improve service delivery.

• In the two years prior to inspection, Developing Initiatives forSupport in the Community had undergone significant changesin leadership and service delivery with a number of transitionsof staff and resources. Despite this, most staff told us they werehappy in their roles, describing good morale and relationshipswithin their teams.

• Developing Initiatives for Support in the Community werecommitted to quality improvement and innovation, involvingthe widespread use of external standards andframeworks. Developing Initiatives for Support in theCommunity were committed to gathering input from clients todevelop their service and improve the design and delivery.Managers attended external conferences and forums to ensurethe service inputted into national agendas and helped to shapeservice delivery.




Mental Capacity Act and Deprivation of Liberty Safeguards

Staff had access to electronic learning on the MentalCapacity Act, which was mandatory. However,compliance with this training was 53% across the threehubs in the Forward Leeds service.

Developing Initiatives for Support in the Community didnot have a policy on the Mental Capacity Act or aprocedure available to guide staff in how they shouldassess capacity or demonstrate decision-making capacityin the client record. Staff did have access to an easy readguide on the Mental Capacity Act (2005) and the MentalCapacity Act Code of Practice was available on the sharedinternal drive.

Across the Forward Leeds hubs, staff understanding ofthe Mental Capacity Act and the application of the Actwithin their role was varied. Staff told us that they would

record any concerns about a client’s capacity and anydecisions made in the client record, but most staff saidthey had not had a situation where this had beenrequired.

At the North Yorkshire Horizons hubs, staff we spoke withunderstood about the Mental Capacity Act and how itapplied to their clients. Staff advised they would seeksupport from their manager if they had queries about theMental Capacity Act.

At the time of the inspection, the provider did not havearrangements in place to monitor the application of theMental Capacity Act or considerations around a client’scapacity to consent to treatment or interventions.However, the data manager was considering how thiswould be possible using the current electronic recordingsystem. Developing Initiatives for Support in theCommunity did not have a Mental Capacity Act lead tosupport staff and clients in the application of the Act.

Detailed findings from this inspection


Safe

EffectiveCaringResponsiveWell-led

Are substance misuse services safe?

Safe and clean environment

Each Developing Initiatives for Support in the Communityhub had a premises file that contained key health andsafety information such as the gas safety record, electricalappliance testing certificate and details of wastemanagement contracts. We saw the electrical appliancetesting certificate was in date for all sites. DevelopingInitiatives for Support in the Community had a contractwith an external company to shred confidential waste andarchive old confidential information.

Managers told us that fire wardens, first aiders, health andsafety champions and infection control champions were inplace at all hubs. Fire wardens were responsible for theweekly fire alarm testing and fire extinguisher checks. Allvisitors received a health and safety information leafletwhen they attended the premises.

There were folders at each hub containing details ofcontrolled substances that are hazardous to health, withdata sheets for each product. Rooms and cupboardscontaining controlled substances that are hazardous tohealth were clearly identified by a laminated poster on thedoor.

As the lead contract holders for Forward Leeds, DevelopingInitiatives for Support in the Community were theleaseholders of the three main substance misuse hubpremises: Armley Park Court, Irford House and Kirkgate.The management of the premises was the responsibility ofDeveloping Initiatives for Support in the Community. Theyhad a central health and safety department whichsupported the hubs, ensuring that any new legislation wascascaded. Within Forward Leeds, each site had a premisesmanagement lead.

The environments at Scarborough, Northallerton andHalifax were clean and well maintained. However, at theKirkgate hub, we observed a stained chair in the downstairsinterview room and broken furniture at the bottom of thestairs near the needle exchange. Clients did not use thisarea but it looked untidy. At Armley Park Court hub, someof the areas were in poor decorative order. In some areas,including one group room, paint was peeling from thewalls.

Premises at Forward Leeds were for the most part visiblyclean. We saw up to date cleaning rotas in place at mosthubs. However, at Armley Park Court and Irford Househubs, we did not see cleaning schedules showing regularcleaning at the time of inspection. Managers told us theycarried out informal environmental checks of the buildingdaily. Following the inspection, the provider submitted thecleaning schedules for Armley Park Court and Irford House.They also told us that their infection control audits hadfound cleaning schedules to be completed. At Kirkgate,cleaning schedules were in place in each room and staffsigned to confirm the cleaning had been completed in linewith the required schedule. However, two client fridges andthe staff microwave and fridge at this hub were unclean.There were dirty trolleys in two clinic rooms, one of whichhad a red stain. None of these items were identified on thecleaning schedules at any of the Forward Leeds hubs. Onthe final day of the inspection, the cleaning schedule in thestaff toilet had not been completed to confirm it had beencleaned. We informed the manager who attended to thisimmediately.

Other partners in each service had the responsibility for theneedle exchange, clinical environment, clinical stock andclinical waste. However, as the lead contract holder withinForward Leeds, Developing Initiatives for Support in theCommunity had a responsibility to ensure these serviceshad adequate systems in place to deliver safe care and

Substancemisuseservices

Substance misuse services


treatment. During the inspection, we reviewed theprovision and storage of vaccines, clinical wastemanagement, clinic supplies and the environment. We alsoreviewed the needle exchange provision and environment.

At the Northallerton, Scarborough and Halifax hubs wefound clinic rooms were well stocked with equipment indate. Armley Park Court and Irford House clinic rooms werealso well-stocked and in good order. There was biohazardspill kits and bodily fluid cleaning kits available at all sites.Clinic rooms contained an examination couch, along withblood pressure monitors and breathalyser testingmachines. All equipment was calibrated in line withmanufacturer’s recommendations. Height measures andweighing scales were also available at all sites. First aidboxes were fully stocked and items were in date. At allhubs, the needle exchange rooms were tidy and wellstocked, all of which was in date.

The testing rooms in the Kirkgate hub were not fullystocked. There were no aprons or hand-towels in theground floor and first floor testing areas. Staff we spoke towere not clear whose role it was to fill these up or when. Weinformed the hub manager at the time and when wereturned the following day, stocks had been replenished.

Staff conducted monthly building checks and health andsafety audits for fire, emergency lighting, signage and hotand cold water temperatures. The area managerconducted a health and safety audit at Forward Leeds inFebruary 2016, which identified that the service should alsobe carrying out hot and cold water checks monthly asidentified in the legionella risk assessment. Eight infectioncontrol audits were completed by Developing Initiatives forSupport in the Community in line with their policy,between April 2016 and August 2016. However, not all hotwater checks had been completed at the Irford House hub.At the Halifax hub, eight infection control audits werecompleted between April 2016 and August 2016. Theservice also had an up to date legionella risk assessmentand evidence of regular water testing.

Developing Initiatives for Support in the Community had ahealth and safety policy and procedure and an infectioncontrol policy statement and guidance. At all hubs, wefound adequate hand washing facilities. Waste segregationnotices were observed in clinical and urine testing areas.However, only 3% of staff had completed the mandatorytraining for infection control at the Halifax hub and only 2%of staff at Forward Leeds.

Clinical and sharps waste ready for collection was stored inlockable cupboards at all hubs. However, at the ArmleyPark Court hub and the Kirkgate hub, this was not alwayscompletely segregated from other waste and stock. TheKirkgate hub had a locked cupboard where waste wasstored. A black carrier bag containing a small full sharpsbox was inside the cupboard. This small sharps box shouldhave been contained in a larger yellow bin which shouldthen have been sealed prior to storage, as outlined in theprovider's policy and the clinical waste contractor’sguidance sheet. The clinical team leader from thepartnership agency agreed that this was the case andimmediately rectified it.

At the time of inspection, the waste cupboard at theKirkgate hub was full. Waste collection was arranged via anexternal contractor each fortnight. Therefore, a full sealedcontainer of used urine pots was stored in the adjacenturine testing area alongside clean unused stock. In theurine testing area, we saw clinical waste bins containingurine testing pots without lids. Staff told us that they hadno formal training to complete urine testing in line withinfection control procedures. Developing Initiatives forSupport in the Community staff were also responsible attimes for removing clinical and sharp waste without havinghad appropriate instruction or training.

Staff we spoke with confirmed that they put usedbreathalyser tubes into general waste paper bins. ForwardLeeds infection, prevention and control policy stated thatused breathalyser tubes should go in the orange bags forthe clinical waste stream. This contradicted guidanceissued by the external waste collection contractor whichstated that these tubes should be placed in tiger stripedwaste bags for the offensive waste stream. We did notobserve any offensive waste streams at any of the hubs.

In line with national regulations, the infection preventionand control protocol used as a guide for all Forward Leedsstaff stated that all consignment notices should be storedon site where the clinical waste was collected from. Therewas confusion around the storage of consignment noticesand these could not be readily located during theinspection. At the Kirkgate hub, the last consignment noticewas eventually located but the rest of the consignmentnotices could not be found. The provider planned toinvestigate this, ensuring that consignment notices wereaccounted for or backdated and subsequently kept in acentral place in the reception area and clearly labelled.




Not all these concerns could be directly attributed to oneprovider in the Forward Leeds service, as infection controland clinical waste was an area that involved allstaff. Developing Initiatives for Support in the Communitystaff were not aware of their responsibility with regard toinfection control and clinical waste. Developing Initiativesfor Support in the Community, as the lead contract holder,did not have sufficient over-sight of these infection controland clinical waste procedures to ensure that the systemswere adequate to maintain client and staff safety. Inresponse to the findings, Forward Leeds had formed aninfection control action group, where they would agree aninfection control action plan for all staff, with the firstmeeting planned for January 2017.

At all hubs, visitors and staff had to sign into the building.All client accessible rooms at Halifax and Forward Leedshad fixed emergency alarms. If an alarm was activated thiswas highlighted on a panel in the reception, next to whichwas a map of the building to enable the first responder toquickly assist. The service identified a ‘first responder’ eachday as it had been identified that if just one member ofstaff initially attended it would often calm the situation.Access to the hubs varied, with some having a buzzer andcamera entry system. Staff escorted clients around thebuildings. Many rooms, such as clinic and treatment rooms,had a keypad entry system and were kept locked at alltimes.

Safe staffing

Staffing levels were determined by contract arrangementsat each hub and adapted over time depending on theservice need. In October 2016, Developing Initiatives forSupport in the Community reported a total number of 240substantive staff. The overall vacancy rate across allservices as of October 2016 was 4% and the staff turnoverrate was 25%. The percentage of permanent staff sicknessas of October 2016 was 4%.

Developing Initiatives for Support in theCommunity employed 89 whole time equivalent staffacross the Forward Leeds service. The only vacancy was anexecutive director post that was being covered by anoperations director in the interim period. The ForwardLeeds service had three hub managers, four leadpractitioners, a team manager in the young person’sservice, a recovery manager and a single point of contactmanager. The largest proportion of the workforce wererecovery coordinators, with other staff working as building

recovery in the community workers, group workers andrecovery champions. Forward Leeds was supported by sixreception staff and 12 administrative staff across theservices. Developing Initiatives for Support in theCommunity employed two whole time equivalent peermentoring and volunteer coordinators across the hubs inForward Leeds. At the time of the inspection, they had 22volunteers working across the service.

Thirty staff worked at the Halifax hub, including anassertive outreach worker, a harm reduction worker and anumber of recovery workers. As of October 2016, the Halifaxhub had used one agency worker to cover a vacancy. Staffdid not raise concerns regarding staffing and felt there weresufficient staff to ensure the services were provided safely.

The North Yorkshire Horizons service employed 24 staffacross the two hubs we visited. In Northallerton, staff feltthey had sufficient numbers of staff to meet the needs ofthe client group. There was a vacancy for an assessmentand engagement coordinator at the time of inspection,with interviews planned for the following week.

In Scarborough, the staff team included an area manager, alead practitioner, open access and assessment workers,criminal justice workers, recovery coordinators and groupworkers. Following the new contract being awarded inOctober 2014, a number of staff had left their posts. Thishad resulted in uncertainty amongst staff and staff feltunder pressure. There were three vacancies at the time ofour visit, part of which were being covered by one memberof bank staff. There had been problems recruiting to postsin Scarborough, with few applications received toadvertised vacancies. One of the vacant posts had beenadvertised twice but no suitable applications had beenreceived. Staff told us that staffing had improved over thelast six months as vacant posts were filled.

Developing Initiatives for Support in theCommunity employed a quality manager, a data managerand a data analyst. They supported each hub in ensuringthey maintained accurate data and reported this tocommissioners and Public Health England. DevelopingInitiatives for Support in the Community employed a fulltime marketing and communications officer who wasresponsible for all their national and local campaigns. Theyalso employed a full time digital and social media officer tomaintain social media and to work with staff to encouragethem to be involved in live chats.




Developing Initiatives for Support in the Community usedagency staff throughout the hubs. This was as a result ofthe transition of contracts and staff which often left gaps instaffing levels. Forward Leeds did not have a bank of staff tosupport the service. They used agency staff to cover vacantposts or long-term sickness. Agency staff had been used tocover administration posts across all three hubs betweenJuly and October 2016. Managers reported that recruitingto administration posts had been a challenge but thesehad now all been filled. Developing Initiatives for Supportin the Community also used agency staff to fill the recoverycoordinator posts at the beginning of the Forward Leedscontract. At the time of the inspection, three recoverycoordinators working at Forward Leeds were long-termagency staff. As such, they had a good understanding of theclients they were working with. Managers told us that allagency staff received the same induction as staff employedby Developing Initiatives for Support in the Community.

Managers from the clinical provider in Forward Leedsrecognised the national challenge to recruit into clinicalprescribing posts in drug and alcohol treatment services.As the lead contract holders for Forward Leeds, theyworked as a partnership to agree solutions to address this,including offering training to the nursing staff to becomenon-medical prescribers.

Developing Initiatives for Support in the Communityidentified that training was an area for development acrossthe services and they had recently implemented a learningand development strategy for 2016 - 2017. Learning anddevelopment of staff was highlighted by the Investors inPeople report as an area for further work. DevelopingInitiatives for Support in the Community had employed acentral training team, reviewed the staff induction and coretraining programme and developed a training calendar forthe coming year. They were also in the process ofimplementing a new electronic system to collect accuratetraining information, as well as other data.

However, there were concerns about compliance withmandatory training at the time of inspection. DevelopingInitiatives for Support in the Community identifiedmandatory training courses, which included induction,equality and diversity, safeguarding and Mental CapacityAct. Some of the services identified additional mandatorytraining for staff at a local level. At Calderdale RecoverySteps, compliance with mandatory training was between80% and 97% for all courses. This service also identified 11

additional local mandatory training courses, including riskassessments, managing challenging behaviour and harmminimisation. Compliance with these training courses wassignificantly lower, with six courses having compliancerates of less than 5%.

Within the Forward Leeds service, compliance was below75% for all mandatory training courses, with the exceptionof the safeguarding awareness level one training. Prior toinspection, data received by the provider stated thatcompliance with this training was 83%. Following theinspection, the provider told us that 94% of staff withinForward Leeds had completed safeguarding awarenesstraining. Managers told us that they thought that some ofthe compliance training data we had received wasinaccurate and that percentages for some of the courseswere higher. At the time of the inspection, all trainingattendance data was held centrally. Staff reported thattraining was released with too short notice to be able toattend.

Not all managers and leads were clear on what themandatory training was and what mandatory training staffhad completed, as they did not receive this data. Theprovider had recently added a course in positive behaviourto their suite of mandatory training for staff in ForwardLeeds. As this training was being rolled out at the time ofinspection, compliance was low. Staff told us they did notfeel they had the skills or fully understood their role inmanaging challenging behaviour. Three staff in ForwardLeeds reported they had to attend an aggressive incident inthe service without having had this training. The providerassured us that all staff would be able to access training inpositive behaviour over the coming year.

Caseloads varied from 30 to 80 cases depending on staffrole and service model, in relation to integrated deliveryalongside other providers. The electronic managementinformation system allowed staff to monitor caseloads andmanagers reviewed this during supervision. It also allowedmanagers to review discharges and client risk on each staffmember’s caseload to allocate new referrals accordingly.Within Forward Leeds, managers could move staff andresources to areas of the system that had higher demandthan others.

The manager and the assessment and engagement workerat the Northallerton hub held caseloads of around 30clients, while the recovery coordinator and group worker




were working with 50 to 60 clients. Staff reported this wasmanageable. At the Halifax hub, caseloads ranged between30 to 40 clients and staff did not raise any concerns aboutthis.

The highest caseloads were in the active recovery teamwithin the Forward Leeds service. At the time of theinspection, staff had between 70 and 80 clients on theircaseload. This team worked with clients with alcoholdependence, heroin and crack addiction. Managers told usthat staff used a ‘red, amber, green’ assessment tool tomanage the clients on their caseload and determine howoften they would need to see their clients. However, not allstaff we spoke with used this tool and some staff told usthey just used their knowledge of the clients on theircaseload. Staff recognised that using the tool wouldprovide a consistent approach for all clients. Staff in theactive recovery team told us they generally found it difficultto manage the number of clients on their caseloads andthis became more challenging when clients did not attendappointments.

Within Forward Leeds, managers and doctors wereavailable throughout the day to support prescribing staffand recovery coordinators. Whilst other doctors wereholding clinics, a duty doctor was allocated to providecover for urgent clinical advice, such as a client releasedfrom prison or attending with a physical health problem.

The Developing Initiatives for Support in the Communityrecruitment and selection policies and proceduressupported safe recruitment, which included obtaining tworeferences. They closely monitored the disclosure andbarring service checks of staff and volunteers and haddeveloped a training session and guidance for managers incompleting the positive disclosure risk assessment.Developing Initiatives for Support in the Communityenrolled with an online system that allowed them to seeconvictions prior to results being sent out in the post.

Assessing and managing risk to clients and staff

Developing Initiatives for Support in the Community had anelectronic case management system for all staff to use. Theinitial risk assessment questionnaire included substanceuse, harm minimisation, physical and mental health, risk inrelation to others, safeguarding children and offendingbehaviour. Staff were provided with prompts to develop anarrative risk management plan, which staff then rated asno risk, low risk or high risk.

Of the 62 records that we reviewed, all the records had riskassessments completed. At the Scarborough andNorthallerton hubs, we found no issues with riskassessments. At the Halifax hub, one risk management planwas not up to date. This was of concern as the client hadrecently attempted suicide, yet their documented risk levelremained low. Four of the 20 client records at Halifaxcontained very little detail in the risk management plans.Staff identified risk but provided minimal detail on how tomanage the risk. Staff in the Calderdale Recovery Stepsservice were planning to review the electronic riskassessment template and develop a risk managementstrategy for use across the services.

In Forward Leeds, staff did not include all identified risks inthe risk assessment or the risk management plan. In two ofthe records where clients had been involved in the criminaljustice system, there was no information about this in therisk assessment or in the risk management plan. In onerecord, staff had not reflected the client’s extensive historyof self-harm in their risk assessment. In another record,staff had not identified all the potential risk posed by aclient attending the service that had committed specificoffences, or mitigate these. Out of the 24 electronic carerecords that we reviewed in Forward Leeds, only twocompleted the risk management actions in the riskmanagement template. As such, the rest of the riskmanagement plans did not actually contain a plan. The riskmanagement plans instead contained additional riskassessment information, rather than a plan of how tomanage the identified risks. We did observe harmminimisation advice offered, but only in a small number ofrecords and this was in the body of the record rather thanin the risk management plan.

Six records in Forward Leeds did not have their riskassessment or risk management plans reviewed within 12weeks, in line with national guidance and DevelopingInitiatives for Support in the Community policy. We alsoreviewed four records where clients frequently did notattend their appointments. Staff had not identified this inthe client’s risk assessment or recorded any strategies theywere using to engage these clients. Managers were awareof these issues. The provider told us they had identifiedthese issues through their own internal audits and had anaction plan in place to address them, including further stafftraining.




In Forward Leeds, four of the 24 records we reviewedidentified that the clients had children. Staff had notexplored the level of contact clients had with their children,or liaised with their manager or other services in line withinformation sharing protocols. There was no evidence ofdiscussion of the impact of parental substance misuse onthe child. One of these records mentioned a home visit forclients with children, but this was not undertaken. Staffseemed unclear about when they needed to completehome visits where clients disclosed that they had childrenand others said that they did not have the time to schedulethese visits.

North Yorkshire Horizons were rolling out hidden harm andhome visit training to all new staff that were beingrecruited. This had been developed by the DevelopingInitiatives for Support in the Community safeguarding leadand was due to be completed by the end of December2016. Staff looked at the harm to children that a client’ssubstance misuse could cause and Developing Initiativesfor Support in the Community offered a course titled‘through my child’s eye’. This focused on supporting clientsto consider the impact of their own behaviour on theirchildren. One client told us the course had beeninstrumental in helping them to abstain from substances.

Forward Leeds did not have a policy or procedure forchildren attending with clients to guide staff on how thisshould be managed. Some staff said they would ask themto wait in one of the one to one rooms rather than the busyreception area, although there was no consistentapproach. We were concerned to see children in all thereception areas we inspected in Forward Leeds, one ofwhich was very busy at the time the children were inattendance.

Developing Initiatives for Support in the Community hadsafeguarding adult and child protection policy statements,both ratified in November 2016, with associated guidanceto support staff in their role. Information for staff on how tomake safeguarding referrals and who to contact were alsoincluded in the staff handbook. The provider’s electroniccase management system had a specific page for recordinginformation relating to safeguarding. Where an externalsafeguarding referral was made, this was recorded andmonitored through the online management informationsystem. It recorded which safeguarding body the referralwas made to, the type of abuse, details of the concerns, theinitial outcome following referral and the final outcome.

Developing Initiatives for Support in the Community hadcommissioned an external training company to review theirsafeguarding training. This was being rolled out at the timeof inspection and was delivered in three levels; awareness,alerter and responder. The provider told us that the coursewas independently accredited for content and quality. Allstaff were required to attend awareness training,operational staff to attend alerter training and safeguardingleads and managers to attend responder training.Developing Initiatives for Support in the Communityprovided us with training information that showed 83% ofstaff at Forward Leeds had completed the safeguardingawareness training and 97% of staff at Calderdale RecoverySteps. Managers at the Northallerton and Scarboroughhubs reported all staff were compliant with this training.The compliance rates provided at the time of inspection forattendance at the alerter level two and responder levelthree training were much lower. Following the inspection,the provider stated that the training was in the process ofbeing rolled out. Therefore, they would not have expectedstaff to have attended at the time of inspection.

Staff demonstrated a good understanding of safeguardingchildren and adults, including the types of abuse, when tomake appropriate referrals and where to make the referrals.Staff received safeguarding supervision with their linemanagers in their quarterly supervision meetings. We sawevidence in client records at the Halifax hub of staffrecording these discussions with their managers. Casediscussions, including safeguarding concerns were alsodiscussed in the team meetings and we observed thisduring the inspection.

Medicines management was the responsibility of theclinical provider at each site. However, as the lead contractholder Developing Initiatives for Support in the Communityhad a responsibility to ensure the safe care and treatmentof all clients.

Fridges at all the hubs in Forward Leeds and the Halifaxhub in Calderdale Recovery Steps contained combinedhepatitis A and B vaccinations, which were in date. A coldchain system was in place at all sites to ensure staffmonitored the fridge temperatures and completed therequired checks. Fridges were lockable and had externaltemperature monitors in place.

At the Halifax hub, emergency medicines boxes containednaloxone, chlophenamine injections, adrenaline injectionsand hydrocortisone and water injections. They also




contained syringes and airways. These were all in date andaudits were regularly completed. The hub also had adefibrillator which staff checked on a weekly basis. In allForward Leeds hubs, emergency drugs were present andstored in locked clinical areas. However, thechlorpheniramine was out of date at Armley Park Court,paracetamol was stored with the emergency drugs at IrfordHouse and a needle had been taped to the pre-preparedadrenaline which did not require a needle. At the Kirkgatehub, there were notices directing staff to the room wherethe emergency medicines were kept but not to the place inthe room where they were kept. The medicines were storedon top of the fridge and not in a place that would havebeen easily found. These concerns were raised during theinspection and rectified by the provider immediately.

We reviewed practices around prescription storage andprescription transport at the Forward Leeds service. Wehad no concerns about prescription management, storageor transportation. However, there was confusion by onestaff member around where the prescription safe keys werestored when the service was closed. We informedmanagers at the time of our inspection who have sincereviewed this procedure and are in the process ofaddressing it as a partnership.

Developing Initiatives for Support in the Community had alone working policy in place. Staff ensured that othersknew where they were going and documented this onboards or in signing out books. Staff were supplied withmobile phones and emergency alarms in some hubs. Staffreported they would visit in pairs or see clients at a GPsurgery or the hub if they had concerns about risk.

Track record on safety

There had been no serious incidents requiring investigationin the 12 months prior to the inspection at any hubs. Therehad been no safeguarding alerts or concerns raised withthe CQC in the 12 months prior to inspection.

Medicines management was led by the clinical providerand not Developing Initiatives for Support in theCommunity in the Forward Leeds consortium. However,Developing Initiatives for Support in the Communitycollated the data on all medicines related errors as part oftheir incident reporting. Between 1 June 2016 and the 1December 2016, there were 58 incidents recorded relatingto prescribing, dispensing, the pharmacy, or lostprescriptions.

Developing Initiatives for Support in theCommunity reported expected and unexpected deaths tothe CQC as required. At Forward Leeds, there had been 24deaths recorded as incidents between the 1 June 2016 and1 December 2016. The services operated a drug relateddeath and drug and alcohol related death panel processwhich reported into the integrated governance board. Theintegrated governance board was chaired by an externaldoctor who assisted the provider in reviewing incidents anddeaths. There were no concerns regarding the providerrecorded in the coroner’s learning from the cause of deathand preventing deaths report.

Reporting incidents and learning from when things gowrong

Developing Initiatives for Support in the Community had anincident and serious incident policy. Staff reportedincidents and serious incidents on the provider’smanagement information system. The hub manager,quality manager and operations director would then benotified by email that an incident had been recorded onthe system. Senior staff were required to provide a qualitycheck and flag any incidents that met the threshold of aserious incident.

All staff understood what types of incidents they shouldreport and gave examples that included deaths,prescribing errors, potential or actual confidentialitybreaches and aggressive or violent behaviour. Staff told usthat debriefs were completed following an incident if it wasrequired. Forward Leeds had also developed a localincident policy that was still in draft format. Managers toldus that incident reporting training had been delivered ateach of the Forward Leeds hub team meetings.

The clinical governance group discussed case studies andclinical incidents to identify learning outcomes. A review ofdata earlier this year identified there had been a number ofincidents of challenging behaviour between clients andstaff. In response, Developing Initiatives for Support in theCommunity were rolling out challenging behaviour trainingto staff.

The quality manager presented quarterly reports to theintegrated governance board, which identified trends andlearning from incidents, safeguarding alerts andcomplaints. We reviewed the minutes of the last threemeetings of the integrated governance board, operationalmanagement group meetings and hub meetings. All had




standing agenda items on incidents and deaths andshowed that information was shared between senior staffat head office and staff in the hubs. This was cascadedthrough team meetings, hub meetings, lead practitionerforums, flash meetings, staff supervision and the electronicnewsletter. Staff confirmed that learning from incidentswas shared in this way.

All staff described a positive culture towards reportingincidents, and were able to offer examples where learningfrom incidents had resulted in a change in the service. AtCalderdale Recovery Steps, staff gave an example oflearning from incidents that was shared with partneragencies. The service had not been made aware of a clientwho attended court and was granted bail, leading to adelay in treatment for their substance misuse. A reviewtook place with identified actions which improved theliaison between Developing Initiatives for Support in theCommunity, court staff and probation staff through thesingle point of contact.

Staff gave examples in Forward Leeds regardingamendments to the lone working policy and procedurefollowing incidents where staff on outreach had beenunable to contact the service. The incident reporting log wereviewed for incidents between 1 June 2016 and 1December 2016 included actions and learning identified.We observed actions and learning identified for allincidents including the deaths reported and themedication and prescribing incidents.

Duty of candour

The duty of candour is a legal duty on providers to informand apologise to patients if there have been mistakes intheir care that have led to significant harm. DevelopingInitiatives for Support in the Community had a duty ofcandour policy that had recently been ratified in November2016. Senior staff at head office understood the provider’sobligations under duty of candour. The quality managerreported that there had been no incidents in the previous12 months that met the threshold for duty of candour.However, they did not grade their incidents in terms oflevels of harm. This made it difficult for the provider toaccurately monitor which incidents had caused moderateor significant harm.

All staff at Forward Leeds told us that they worked in atransparent way with clients and were open and honest ifincidents or mistakes happened. They were aware of the

need to keep clients fully informed and providedinformation throughout any investigations or complaintsmade. Staff were able to give examples where clients hadreceived feedback in response to incidents or complaints.

Staff within the North Yorkshire Horizons service wereunsure about the duty of candour. They thought they haddiscussed it in a recent team meeting but we were unableto find evidence to support this in the minutes of teammeetings that we reviewed as part of our inspection.

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

Assessment of needs and planning of care

All electronic care records we viewed had a comprehensiveassessment with evidence of ongoing assessmentthroughout the client’s notes. For example, where clientsidentified that their drinking, depression, and/or anxietyhad increased, recovery coordinators had completed theevidence based tool on the system to assess this further.However, two of the records that we reviewed in ForwardLeeds had limited assessment information about theclients offending behaviour, despite evidence that they hadrecently been through the criminal justice system.

Developing Initiatives for Support in theCommunity required staff to review all clients’ treatment ata minimum every 12 weeks at a ‘milestoneappointment’. The provider described the ‘milestoneappointment’ as the treatment and care review, whichinvolved all professionals that were supporting the client.Staff would review risk and recovery plans at thisappointment.

All electronic care records we reviewed had a recovery planpresent. However, eight of the 24 recovery plans in ForwardLeeds had not been reviewed within 12 weeks in line withnational guidance and Developing Initiatives for Support inthe Community policy. The recovery plans we reviewed inForward Leeds did not contain sufficient detail and theidentified goals were not tailored to the individual. Forexample, recovery plans set a goal to reduce drug oralcohol use, but did not detail by how much and by when.Staff did not always reflect interventions or ongoingsupport in the recovery plans, such as referrals that had




been made for support with education, training andemployment. We saw one record where a client reportedthey were a carer, yet this information was not captured inthe recovery plan, with no identified support for that client.

The recovery plans at North Yorkshire Horizons weredetailed, personalised and holistic. In the Halifax hub, 14out of 20 records had detailed recovery plans that were upto date, personalised and recovery orientated. The sixrecords that did not meet this standard lacked detail, didnot reflect the clients’ views and were not recoveryorientated. We did see evidence of recovery capital in theclient records. Recovery capital is a term used to predictthe likelihood of achieving sustained recovery. The planswere linked to five ways of wellbeing: complementarytherapies, healthy living support, education and training,improve socio-economic sustainability and involved involunteering. Recovery plans were linked to theseindicators as and when clients were in a position to startundertaking this work. This enabled the service to measurehow clients were accessing recovery capital opportunities.

The client electronic record allowed staff to select theinterventions that they had delivered to the client at thetime of the appointment. Interventions were mapped tothe recovery road maps for drugs and alcohol. The recoveryroad map identified the pharmacological and psychosocialinterventions and recovery support that a client shouldreceive at each stage of their treatment.

We saw evidence of motivational interviewing techniques,solution focussed interventions and internationaltreatment effectiveness programme mapping used in oneto one appointments with recovery coordinators. We alsosaw staff using drinks diaries with alcohol clients.

All client information was stored on the client electroniccare record used by all the providers in the services. Accessto these systems was password protected. DevelopingInitiatives for Support in the Community had informationgovernance policies and procedures in place to guide staff,which they could access on the staff intranet. Managerstold us that all staff, including agency staff, had to completea one day training course on the electronic care recordsystems before they could use it. Information governancewas also part of the electronic learning induction. Wherestaff used any paper based records, these would bescanned or inputted onto the electronic system.

The director of service was the security information riskofficer for the organisation and coordinated requests foraccess to client and staff records in line with the DataProtection Act. The chief executive officer was the CaldicottGuardian for the organisation. A Caldicott Guardian is asenior person responsible for protecting the confidentialityof patient and service-user information and enablingappropriate information-sharing.

Best practice in treatment and care

Developing Initiatives for Support in the Community had aquarterly drug and alcohol development group, which wasattended by representatives from all the services, inaddition to monthly meetings at each service. At thesemeetings, staff reviewed best practice and currentguidance, agreeing a plan on how to deliver best practiceacross all services.

Developing Initiatives for Support in the Community werenot directly responsible for the delivery of clinicaltreatment in Forward Leeds. However, as the lead contractholder for Forward Leeds they were responsible forensuring that all the interventions across the service wereunderpinned by national guidance. Developing Initiativesfor Support in the Community had developed specificrecovery road maps for drug and alcohol in North YorkshireHorizons. They had also developed these alongside one oftheir partnership organisations in both CalderdaleRecovery Steps and Forward Leeds. These recovery roadmaps were divided into nine stages, with each stageincluding pharmacological interventions, psychosocialinterventions and recovery support as appropriate to eachof the stages. These interventions were underpinned bynational guidance, including the Strang (2011): Medicationsin recovery re-orientating drug dependence treatment. Therecovery road maps were in both the staff handbook andthe service user handbook. This enabled staff and clients tosee what stage in their treatment they were at and whatinterventions could be delivered.

We also saw how Developing Initiatives for Support in theCommunity staff worked in partnership with clinical staffwith regard to pharmacological interventions. Urine or oralswab tests were completed by all staff in Forward Leeds,including the recovery coordinators. These were completedprior to the client starting treatment to confirm drug useand at regular intervals throughout treatment. DevelopingInitiatives for Support in the Community staff also usedbreathalysers to determine the client’s use of alcohol, for




example before picking up their prescription formedication. Along with the clinical administration teams,the recovery coordinators would also liaise withpharmacies around medication and engagement. Therecovery coordinator would discuss the appropriate actionwith a prescriber if the clients had not picked up theirmedication from the pharmacy as required

Staff were able to quote the best practice guidance thatwas appropriate to the treatment and care delivered,including the Department of Health (England) (2007) Drugmisuse and dependence: UK guidelines on clinicalmanagement and the development of administrations.Client records showed that staff deliveredharm-minimisation and clients were offered blood bornevirus testing, immunisation and signposted to treatment ifthey wanted it. Staff delivered psychosocial interventionsunderpinned by motivational interviewing, solutionfocussed and cognitive behavioural techniques. Therecovery plan used by Developing Initiatives for Support inthe Community and some of the work completed withclients in the group sessions was based on the PublicHealth England International Treatment EffectivenessProgramme link node mapping (mind mapping) manuals.Staff told us that they signposted clients to mutual aid andreferred them internally within DISC for education, trainingand employment and housing support. This was to supportclients in building recovery capital in line with Strang/National Treatment Agency (2011): Building recovery incommunities.

Where clients were receiving support for their opiatedependence, Forward Leeds offered a choice of medicationbetween methadone, buprenorphine and naltrexone.Where possible, staff planned 12 weekly reviewappointments with the prescriber, the recovery coordinatorand the client. This is all recommended within the NationalInstitute of Health and Care Excellence (2007) clinicalguideline 52 for opioid detoxification.

North Yorkshire Horizons were reviewing their newprescribing process at the time of inspection. Harmreduction leads in the North Yorkshire Horizons hub werealso rolling out the prescribing of naloxone. Naloxone is anemergency medication used in cases of opiate overdose.This had been agreed with commissioners and the processwas due for completion by December 2016.

Forward Leeds offered clients a physical health assessmentat the beginning of treatment and offered smoking

cessation. Physical health was reassessed where this wasidentified as needed by the Forward Leedsclinicians. Developing Initiatives for Support in theCommunity staff liaised with other providers in their serviceand external agencies to address physical and mentalhealth concerns. For example, staff would arrange bloodborne virus appointments with the Forward Leeds clinicalservice. Clients were signposted to their own GP to addresstheir physical health needs. A pathway with the hospitalhepatology department in Leeds was in place to increaseengagement and uptake in treatment.

All clients who were prescribed over 100ml of methadonehad to have an electrocardiogram in accordance withnational guidance. The electrocardiogram measured forpotential heart abnormalities which clients on high dosemedication had an increased likelihood ofsuffering. Developing Initiatives for Support in theCommunity had a system in place to monitor that thesewere completed as required.

We also reviewed the specialist alcohol prescribingguidelines and the alcohol treatment provision. Wereviewed two records in Forward Leeds for clients who hadcompleted an alcohol detoxification in the community. Allclients accessing the service for their alcohol misuse had acomprehensive assessment using evidence basedscreening tools, including the alcohol use disorderidentification test, the Leeds Dependency questionnaireand a liver function test. Only clients that had low leveldependency, low risk of seizures and family or carersupport, were able to complete a community alcoholdetoxification. A reducing dose of chloroziazapozidemedication was prescribed for the client to assist with thesafe withdrawal from alcohol. Relapse preventionmedication was prescribed post detoxification. This was inline with NHS National Treatment Agency Review ofEffective Treatment for Alcohol guidance and NationalInstitute of Health and Care Excellence clinical guidance.

Recovery coordinators completed nationally recognisedtools for anxiety and depression with clients, including thegeneralised anxiety disorder -7 and the patient healthquestionnaire -9. These were completed at the start oftreatment as part of the screening assessment and thenreviewed and revisited where need was identified.




Client progress and changes were measured using thethree monthly treatment outcome profiles. This is amonitoring tool developed by the National TreatmentAgency and reported through the National Drug TreatmentMonitoring System.

Information governance audits and case file audits werecompleted at all hubs. Other audits completed by theservice related to the safety of the service, rather thanclinical audit. These included a hand washing audit, ahealth and safety audit and quarterly infection controlaudits.

Skilled staff to deliver care

Within Forward Leeds, Developing Initiatives for Support inthe Community had contract arrangements with four otherproviders to deliver a range of treatment options andsupport to clients. A similar arrangement was in place atNorth Yorkshire Horizons and Calderdale Recovery Steps,although on a smaller scale and with fewer providersinvolved. A range of multidisciplinary professionals wereemployed to provide care and treatment such as doctors,nurses, and recovery coordinators. Many of them wereco-located at each of the hubs. Staff we spoke withdescribed this as one of the strong points of the hubs. Theysaid that staff with different skills and experience werealways available to discuss clients’ needs and offersuggestions about treatment options. This felt supportivefor the staff member and also helped them to support theclients that they were working with.

Developing Initiatives for Support in the Community usedrole-specific job descriptions and personal specifications inrecruiting staff. Staff were subject to panel interviews andreferences prior to appointment. Developing Initiatives forSupport in the Community also recruited a number ofvolunteers across their services. In each service, a staffmember provided a volunteer lead role, supported by avolunteer manager based at head office. Volunteers wespoke with were positive about their experience. They feltvalued, supported and reported they received a good levelof training. Volunteers had access to supervision and hadregular meetings.

Developing Initiatives for Support in the Community had anine month probation period for new staff to ensure thatthey were competent in their role and identify if theyneeded any additional support. Staff were reviewed at four

months and eight months as part of their probation period.We observed a probationary review at Forward Leeds,which had been completed within these timescales andincluded development milestones.

Eight staff at Forward Leeds confirmed they had either nothad an induction, had waited over six months or hadwaited over 12 months. One staff member said they hadnot been shown around the building or had basic drugawareness. There was no evidence of induction plans forstaff in the supervision files. Managers at Forward Leedscould not confirm that their staff had received anappropriate induction. This meant that not all staff had thetraining to support them in maintaining their own safety atwork and that of the client.

The induction was a mixture of electronic learning and atwo day face to face training course. The provider told usthat staff received a local induction within the first twoweeks of employment. There was no formalisedmonitoring of local induction, however the provider told usthat records were kept in relation to some elements,including the completion of the electronic system training.The local induction included the following:

• Training in the electronic system by the data team andsenior administrator

• Data Protection / Information Governance e-learning• A tour of the building including fire alarms, exits /

procedures, first aid resources by the senioradministrator

• Traceability systems depending on staff role• Discussion around key requirements of the role with

the line manager• Shadowing of more experienced members of staff• Meeting with a member of senior management within

the service

The corporate induction was expected to be completed bystaff by the end of their nine month probationary period.This meant that staff could be in post up to nine months,without having completed the following training:

Day 1:

• Charter of Values• Drugs Policy• Service User Influence & Involvement

Day 2:

• General Health & Safety




• Blood Borne Viruses• Lone Working/Traceability/Violence in the Workplace

Prior to the inspection, the provider submitted datashowing that 72% of Forward Leeds staff had completedthe electronic learning induction, 50% had completed theinduction day one and 53% had completed day two.Compliance with induction was 100% at the Scarboroughhub and 75% at the Northallerton hub, with one newstarter due to complete it. Following the inspection, theprovider stated that the figures given had included staffwho had recently commenced employment and would nothave been expected to have fully completed theircorporate induction. The gave revised figures that inForward Leeds, 79% of staff had completed the electroniclearning, 60% had completed induction day one and 66%had completed induction day two. They also stated that86% of staff had completed their induction at theNorthallerton hub. Senior managers identified the rapidexpansion of services within Forward Leeds as the reasonfor the delay in staff induction. Following the inspection,the provider informed us that they had reviewed theirinduction processes to increase local ownership ofinduction and that this would be accompanied bymonitoring locally.

Developing Initiatives for Support in the Community had astaff performance and supervision policy and procedure,which included guidance for staff on supervision,probationary reviews and appraisals. Staff received annualappraisals and minimum quarterly supervision. Wereviewed fifteen DISC staff supervision records at theForward Leeds service. All the supervision records wereviewed demonstrated that staff received supervision inline with the provider's supervision policy. Some linemanagers we spoke with attempted to offer supervisionmore frequently, at either six or four week intervals. Threestaff we spoke with felt quarterly supervision was notsufficient and left them feeling unsupported at times.

We reviewed six staff appraisals at Forward Leeds. Dataprovided by Developing Initiatives for Support in theCommunity prior to inspection showed that 95% of staffwho were eligible had received their annual appraisal.Those who had not were either absent from work or new inpost. The six appraisals that we reviewed included aself-appraisal section, manager feedback and individualobjectives. However, objectives were not always specificand personalised as outlined in the policy and procedure.

As the lead contract holder for Forward Leeds, DevelopingInitiatives for Support in the Community worked with theclinical providers in the consortium to ensure that theirdoctors had been revalidated and that the clinicians andmedical staff held the appropriate qualifications andregistrations. Revalidation is the process by which licenseddoctors are required to demonstrate on a regular basis thatthey are up to date and fit to practise.

Forward Leeds had monthly hub meetings at each of thethree sites, with all staff from the consortium represented.The hub meetings had standard agenda items includingperformance and data, practice development sessions andissues raised by staff for discussion. During the inspection,we observed one of the weekly recovery coordinator teammeetings at Forward Leeds, where 14 staff membersattended. A standard agenda was followed where staffdiscussed items such as data performance reports andvulnerable clients. We observed detailed case discussionabout clients.

Flash meetings were held daily for all staff. These includedany incident feedback, client risk and buildingmanagement issues for that day. We observed a flashmeeting at the Northallerton hub. Staff planned andorganised their work for that day according to client needsand staff cover arrangements. All staff participated in themeeting. A written record of the meeting was kept for futurereference and referred to at the next daily meeting, whichmeant that all information was available for staff andcommunicated effectively.

At Forward Leeds, two of the 21 staff we spoke with told usthat administration and reception staff were not supportedto attend the hub, team meetings or flash meetings. Theysaid they didn’t always feel involved in the service, despitethe extensive contact they had with clients. They gave anexample of where a client, who was deemed at the flashmeeting as not to be permitted in the building, had alreadyattended and was in the reception area by the time theyreceived that information.

Staff in the Scarborough hub reported they felt supportedby managers to attend specialist training. They hadaccessed additional training in areas such as personalitydisorder, suicide and autism. At the Halifax hub, the groupworker had been supported to access specialist training infacilitating group work. At the Northallerton hub, one staffmember was enrolled on the graduate diploma inaddiction studies although funding was not available for




other staff to complete this. Recovery coordinators inForward Leeds had either completed, or were encouragedto complete the national vocation qualification in healthand social care level three. Staff also told us that they wereencouraged to continue with the substance misuse degreecourse provided by a local university where they hadalready started it. However, other staff who had notcompleted it told us that Developing Initiatives for Supportin the Community were no longer funding this course.

Developing Initiatives for Support in the Community sentus details of the specialist training courses provided to staff,which included group work, motivational interviewing,solution focussed therapy, international treatmenteffectiveness programme training, modifying offendingbehaviour and understanding and working with mentalhealth. It was not clear how many staff had completed thistraining. Developing Initiatives for Support in theCommunity had not yet mapped their specialist training tothe roles of staff, although this was a planned piece ofwork. Managers told us that all staff had a training needsanalysis completed but we only saw evidence of this in oneof the supervision records that we reviewed. However, inthe Halifax hub, training and development plans werepresent in all files we reviewed.

The Forward Leeds service were developing and reviewingtheir workforce development plan. Following a trainingneeds analysis, they had begun to deliver DevelopingInitiatives for Support in the Community risk managementtraining to all front line staff.

Managers had either completed or were in the process ofcompleting nationally recognised leadership andmanagement qualifications at an appropriate level to theirrole; either level four or level five. Staff confirmed this butthis was not demonstrated in the training data that wereceived. Managers completed training in appraisal andsupervision, business development and disciplinary andgrievance procedures. Managers had also undertakenspecialist training in relation to substance misuse,including motivational interviewing for managers and theinternational treatment effectiveness programme formanagers course.

Developing Initiatives for Support in the Community hadpolicies and procedures in place to support managers inaddressing poor performance. Managers were able to

discuss how they had successfully identified and addressedpoor performance in line with this procedure. There wasevidence of this in one of the supervision records that wereviewed.

Multidisciplinary and inter-agency team work

The managers of each hub attended regular substancemisuse group meetings. This ensured learning and goodpractice was shared across the services with the productionof action and development plans. Each hub engaged inlocal forums, including safeguarding meetings,multi-agency risk assessment conferences and housingforums. Complex client’s needs were met by specific teamswithin integrated services, such as the dual diagnosisprovision in Forward Leeds and police liaison workersbased on site at Calderdale Recovery Steps.

Developing Initiatives for Support in theCommunity worked with criminal justice agencies todeliver rehabilitation to offenders in the community andensure transition for those leaving custody. A dedicatedworker within the Forward Leeds service co-ordinated theapproach to domestic abuse, providing training and liaisingwith other services. Staff supported and signposted clientsto engage in external services, including learning disabilitysupport, education, training and employment and debtmanagement. Developing Initiatives for Support in theCommunity worked closely with partner organisations todeliver integrated services in contracts set out bycommissioners. This included NHS mental health trustsand other providers of substance misuse services.

At each service, Developing Initiatives for Support in theCommunity worked with other providers to deliver careand treatment for clients. We reviewed partnership boardmeeting minutes, integrated governance board meetingminutes and operational meeting minutes. Each providerin the consortium was represented at these meetings. Theydemonstrated a partnership, multidisciplinary approach tothe strategic and operational management of treatmentservices.

The electronic client records we reviewed demonstratedthat each provider worked in partnership to deliver careand treatment. We saw three-way meetings attended bystaff across the services, working together with the client toplan their care. However, staff told us that time limitationsand the co-ordination of diaries often made planning these




meetings difficult. Staff from the different providers wereco-located together in the hubs. They told us that thisfacilitated multi-disciplinary discussions on a regular butmore informal basis.

Managers told us that Forward Leeds had recently started amultidisciplinary meeting including recovery coordinatorsand doctors to discuss some of the more complex cases.The meetings were every two weeks at the Irford hub.Managers told us that staff from other services could add aclient for discussion at these meetings and dial in on aconference call. However, staff at the other hubs were notaware of these multidisciplinary meetings. Managersacknowledged that these meetings were still in theirinfancy and had been developed in response to anincident. They aimed to support communication betweenthe multidisciplinary team and were yet to agree how thelearning from these meetings would be cascaded for allstaff.

Staff at all hubs reported that they had good relationshipswith GP’s, pharmacies, hepatology services, crisis servicesand mental health teams. They also worked closely withhomeless services, services that supported sex-workers,organisations to support relatives and carers and mutualaid groups.

Staff in Calderdale Recovery Steps worked closely with aperinatal clinic based within the local acute hospital. Theyreferred female clients to this specialist pregnancy service,who were supported by a specialist midwife up to six weeksfollowing the birth of their child. Staff attended amulti-agency pregnancy liaison action group, consisting ofspecialist midwifes, police, social services and healthvisitors. Safeguarding procedures were in place and allagencies contributed to supporting these clients. Wevisited this clinic and observed kind and caring interactionsbetween staff and clients.

The Irford House hub provided an evening venue for amutual aid group and the Recovery Academy worked withthe local carers groups to deliver group work. Staffdescribed examples of how they had liaised with theseagencies and records we reviewed showed evidence of staffsignposting and working in partnership with other externalprofessionals.

At the Northallerton hub, a staff member worked with thelocal gym supporting clients who used steroids. The NorthYorkshire Horizons services were part of the safe

prescribing network, working with other organisations toensure the timely collection of prescriptions andmonitoring of illicit drug use on top of prescribedmedication.

Good practice in applying the Mental Capacity Act

Staff had access to electronic learning on the MentalCapacity Act which was mandatory. At the time ofinspection, compliance rates with Mental Capacity Acttraining were as follows:

• Calderdale Recovery Steps 93%

• Forward Leeds 53% - Irford House hub 73%, followed bythe Kirkgate hub with 48%, Armley Park Court with 35%and the young people’s service with 25%.

• North Yorkshire Horizons 84%

Developing Initiatives for Support in the Community didnot have a policy on the Mental Capacity Act. Three otherpolicies made reference to the Act’s five statutoryprinciples, such as the Equality and Diversitypolicy. Developing Initiatives for Support in the Communitydid not have a procedure available to guide staff in howthey should assess capacity or demonstratedecision-making capacity in the client record. Staff didhave access to an easy read guide on the Mental CapacityAct (2005) and the Mental Capacity Act Code of Practice wasavailable on the shared internal drive.

At Forward Leeds, staff understanding of the MentalCapacity Act and the application of the Act within their rolewas varied. Some staff were aware of the need to presumea client has capacity, to note the client’s ability to weigh updecisions and understand information and to makedecisions in the client’s best interests if they lackedcapacity. They gave examples where they would consider aclient’s capacity where they were intoxicated and attendedfor appointments and the action that they would take.Other staff had less understanding and confused mentalhealth with mental capacity. Some staff thought thatconcerns around capacity were more prevalent in the teamthat supported alcohol detoxifications. Recoverycoordinators told us that if they needed additional adviceon mental capacity, they would approach the doctors andother clinicians for additional support, or the operationsdirector.

Staff told us that they would record any concerns about aclient’s capacity and any decisions made in the client




record, but most staff said they had not had a situationwhere this had been required. Two staff mentioned thatthere was a ‘six-item cognitive impairment test’ on theclient electronic recording system where they would recordif they had concerns about memory or cognitivefunctioning that may relate to a client’s capacity.

At the Halifax hub, there was no reference to client’scapacity in 18 records. In the one record that did mentioncapacity, it was evident that the responsibility for assessingcapacity was unclear. Concern was raised by severalprofessionals but capacity was not formally assessed over atwo-month period.

At the North Yorkshire Horizons hubs, staff we spoke withunderstood about the Mental Capacity Act and how itapplied to their clients. Staff said if a client’s capacity toconsent was impaired due to alcohol or drugs, they wouldleave any treatment or decision making until the client wasable to make an informed choice. One staff member gavean example of concerns about capacity issues with oneclient who may be exploited by their family and how theyhad made a referral to the local authority. Staff spoke of anawareness of alcohol related dementia symptoms and howthis could affect capacity to make decisions. Staff advisedthey would seek support from their manager if they hadqueries about the Mental Capacity Act.

At the time of the inspection, Developing Initiatives forSupport in the Community did not have arrangements inplace to monitor the application of the Mental Capacity Actor considerations around a client’s capacity to consent totreatment or interventions. However, the data managerwas considering how this would be possible using thecurrent electronic recording system. Developing Initiativesfor Support in the Community did not have a MentalCapacity Act lead to support staff and clients in theapplication of the Act.

Equality and Diversity

Developing Initiatives for Support in the Community had anequality and diversity policy that outlined adherence tocurrent equality legislation under the Equalities Act 2010.Utilising the Equalities Act’s ‘nine protected characteristics’to define ‘minority groups’, the services aimed to beproactive in establishing pathways for those who may beexcluded. The provider’s ethos was that no society willflourish unless members of that society are given

opportunities and freedoms of equality. DevelopingInitiatives for Support in the Community reported that 34%of their substance misuse clients had a long term illness ordisability.

Developing Initiatives for Support in the Community hadheld the Equality North East ‘Equality Standard GoldAward’ since 2012. Their equality and diversity groupalongside nominated diversity champions implementedand reviewed the equality and diversity action plans withstaff and clients. The North Yorkshire Horizons action planoutlined how the service would support women, victims ofdomestic abuse, sex workers and those with mental healthproblems. When implementing significant changes topolicy or procedure, Developing Initiatives for Support inthe Community completed an equality impact assessmentdocument to reflect where and why change was needed.

Staff received mandatory training in relation to equalityand diversity. However, compliance rates were low acrosssome services. Prior to inspection, the provider submittedtraining figures that showed 87% of staff at CalderdaleRecovery Steps, 52% of staff at Forward Leeds and 38% ofstaff at North Yorkshire Horizons had completed thetraining. Following the inspection, the provider statedthat the training figures given had included staff memberswho had recently commenced employment, who theywould not necessarily expect to have completed thistraining. The revised training figures given for ForwardLeeds were 66% for Forward Leeds and 64% for NorthYorkshire Horizons.

Templates on the electronic client record system wereregularly updated by Developing Initiatives for Support inthe Community, most recently to meet recording in linewith the NHS Accessible Information Standards. The systemflagged vulnerability at the assessment stage, includinglearning disability, pregnancy and dual diagnosis.

Staff worked in a person centred way with clients from arange of different backgrounds and with clients who hadprotected characteristics. During our inspection, weobserved staff working in a way to ensure that all clientsreceived equal treatment and access to services.

Forward Leeds worked closely with local services to ensurethat the care and support offered was available and




appropriate for all clients. Staff promoted the service in thelesbian, gay, bisexual and transgender communities andthe black and minority ethnic communities, to engagepeople in accessing support for drug and alcohol use.

In North Yorkshire Horizons, the equality and diversityworker at the Scarborough hub had attended training onfemale genitalia mutilation and was in the process oflooking how to access the local lesbian, gay, bisexual andtransgender communities. They had also identified thatthere was a large Polish community and had providedinformation in Polish to ensure people knew about theservice.

Staff gave examples of how they had been supported tostay in work where they had physical or mental healthissues, including being supported by the service to getadditional support from access to work budgets.

Management of transition arrangements, referral anddischarge

Clients could access treatment for their substance misusethrough dropping in to one of the substance misuse servicehubs. Within Forward Leeds, open access to services wasalso provided at GP practices that offered primary careextended services. This is where treatment and support isoffered in the local GP practices and is delivered inpartnership between the primary care GP and a substancemisuse service recovery coordinator.

Clients could also be referred to all hubs by their GP or anyother professional. There was an online referral form on theForward Leeds website that could be completed by anyonewho wished to refer themselves or someone else into theservice. Forward Leeds had a single point of contacttelephone number that operated Monday to Friday, 9am to5pm. Outside of these times, an answerphone serviceallowed messages to be left. The single point of contactalso operated in the North Yorkshire Horizons andCalderdale Recovery Steps service.

Early intervention and prevention staff were employed byanother provider that was part of the Forward Leedsservice. Part of their role was to promote Forward Leedsand undertake assertive outreach to actively engage hardto reach groups, such as clients who were homeless.

Clients also accessed Developing Initiatives for Support inthe Community through the criminal justice service, forexample from the prisons, police cells and courts. Forward

Leeds provided the treatment element of some courtorders, including the Drug Rehabilitation Requirement andthe Alcohol Treatment Requirement. They worked closelywith the probation service who provided the supervisionelement of the order. We reviewed two records at ForwardLeeds where clients had been sentenced to a DrugRehabilitation Requirement. We saw evidence of thisongoing communication and joint work between servicesto support the client.

Forward Leeds employed hospital in-reach nurses whoengage with client admitted with an alcohol or opiaterelated accident or illness. Whilst these alcohol liaisonnurses could offer short-term intervention they would referclients into the substance misuse or GP hubs for longerterm treatment.

Forward Leeds provided both a young person’s and anadults’ service. It had a standard operating procedure fortransitioning young people into adult services ensuringthat the clients received treatment in a service that wasmost appropriate for them. Young people aged 18 to 21were supported to move into the adult Forward Leedsprovision when it was appropriate for them.

Developing Initiatives for Support in theCommunity encouraged clients who were post recovery tobecome peer mentors. Peer mentors are current orex-clients who are in recovery, whose role is to supportother clients at the beginning of their recovery journey.Within Forward Leeds, peer mentors supported the deliveryof the groups and activities in the Recovery Academy.Building Recovery in the Community workers worked withclients who were due to be discharged, to identify healthand well-being activities, support groups and volunteeringthat they could continue with when they left treatment.Clients were encouraged to access mutual aid, such asself-management and recovery training groups throughouttheir recovery. This ensured that when they weredischarged from services, they could continue with theirrecovery and access local recovery and communitysupport. Developing Initiatives for Support in theCommunity had employment, training and education andhousing workers who supported clients to build recoverycapital.

Are substance misuse services caring?

Kindness, dignity, respect and support




Within Forward Leeds, the majority of feedback wasextremely positive about the service people received andthe approach from all staff. Whilst there were somenegative comments, these were in relation to cancelled orinsufficient appointments, or being unable to contact theservice by phone. Clients, relatives and carers reported thatstaff were respectful, non-judgemental, kind, and polite.They said that they felt listened to, that staff weresupportive and provided them with guidance in theirrecovery.

One client and their support worker at the North YorkshireHorizons service travelled over an hour to speak to usduring the inspection, as they wanted to tell us in personhow pleased they were with the service they received.Comments from clients included how staff had not givenup on them, how staff inspired them and how staff ensuredthey received a warm welcome when they walked throughthe door.

Clients in the Halifax hub felt care was tailored to theirneeds and that staff listened to them, reporting that staffwere caring and knowledgeable. One of the 17 commentcards received was negative regarding a clinical aspect ofcare. The remainder of the comment cards reflected aconsistent and caring approach by all staff in the service.

Carers reported that staff treat themselves and theirrelatives with kindness and respect. All carers we spoke togave positive feedback, stating staff were helpful,supportive and kept them involved in the care andtreatment being delivered. Carers spoke about staff gainingclient’s consent to share information and contacting themif they had concerns about their relative’s wellbeing.

During the inspection we observed staff interaction withclients on a one to one and group basis. Staff discussed theinterventions available and listened to clients’ views. Allstaff demonstrated an empathic understanding of eachclient’s individual situation and a non-judgementalattitude. They provided encouragement to clients in theirrecovery and offered suggestions of additional support.Staff demonstrated an understanding of the needs of theclients and spoke passionately about the support theyprovided and their roles. At the Halifax hub, we observed avery positive and passionate member of staff facilitate agroup work session. They managed the group very well,giving everyone an opportunity to talk and encouraging thegroup to provide support to each other.

We observed staff who worked in the reception areas of theForward Leeds hubs working hard to manage privacy andconfidentiality in very busy reception areas. This waschallenging due to the numbers of clients attempting toinform reception staff they had arrived. The operationsdirector told us that they worked with staff on their practiceto maintain confidentiality and privacy in the receptionareas. However, there did appear to be confusion aboutwhether clients should write their attendance in the visitorssigning in book. Some staff said that clients wanted to dothis, others said they asked them to sign in or at least writetheir initials in the signing in book. The visitors signing-inbook was open on the reception desk so other clientscould see this. If clients wrote in this book, this had thepotential to compromise a client’s confidentiality. Theoperations director later confirmed that the signing in bookwas for visitors only and revisited this with staff.

Clients at the Northallerton and Scarborough hubs hadrequested a discrete way of informing the receptionist thatthey wanted to access the needle exchange. Staff haddeveloped a card which identified the client wanted to usethe needle exchange, which they could just hand toreception when they arrived. This had been newlyintroduced at Scarborough and was not yet in use atNorthallerton so feedback on its effectiveness had not yetbeen sought.

Any confidentiality breaches were recorded and acted onas incidents, which we confirmed through a review of theincidents data. Developing Initiatives for Support in theCommunity completed quarterly information governanceaudits and all outcomes were shared with the servicesthrough its governance structures.

The involvement of clients in the care they receive

During our inspection, clients told us that their treatmentoptions were explained to them and they were involved indecisions about their care. Following an initial assessment,clients in the Calderdale Recovery Steps service wereoffered an appointment to a ‘choices session’, where staffdiscussed treatment options, including medication andgroup work. Staff across all hubs reported they offered theclients a copy of their recovery plan and clients confirmedthis. Recovery plans had been offered to all the clients inthe 62 electronic client records that we reviewed.

Developing Initiatives for Support in the Community had aninformed consent information sharing agreement that was




completed at the initial contact with the clients. This wasreviewed throughout treatment every three months, orwhen the identified need changed. This included howinformation would be shared with other providers in theservices, as well as with the National Drug TreatmentMonitoring System. The client could agree on the type ofinformation that would be shared and with who, whilstidentifying circumstances where information may beshared without the client’s consent. It also included adviceon the requirements of staff to notify the driver and vehiclelicensing authority under the governments assessingfitness to drive guidance.

Clients were informed of their rights to access their records.Clients we spoke with confirmed that they had signed andunderstood the terms of their confidentiality agreement. All24 records we reviewed at Forward Leeds included acompleted informed consent information sharingagreement. Developing Initiatives for Support in theCommunity completed quarterly information governanceaudits to monitor consent.

During an observation of a one to one session at one of thehubs, the client disclosed thoughts of self-harm. Therecovery worker gained verbal consent from the client tocontact the crisis team and discuss their concerns onbehalf of the client. They also gave the client contactdetails for crisis services.

Family members were involved in the recovery plan anddecision making where appropriate and where consentwas given. During the inspection, we spoke with a client’srelative who had attended an appointment with the client.They said they felt involved in the client’s treatment andthat the worker was really supportive. Staff told us that if afamily member wanted to attend an appointment and theclient agreed, then that would be facilitated. In almost allthe client electronic records we reviewed, relatives andcarers had been identified as a client’s ‘strength’ in therecovery plan. However, there was no further evidence inthe recovery plan or the record to build on this recoverycapital or to demonstrate any further inclusion of familymembers or carers.

Forward Leeds had links with local advocacy services andstaff told us that they would support clients to access theseif it was required. In Calderdale Recovery Steps, access toadvocacy was available through partner organisations,such as the local women’s centre and MIND.

Developing Initiatives for Support in the Community had aservice user influence and involvement policy whichoutlined their approach to involving service users in theplanning and delivery of care and treatment. Each hub hadservice user forums and a service user involvement file anddevelopment plan. Levels of involvement and influenceacross services were monitored, as this was one of their keyperformance indicators. We observed service userinvolvement agenda items in the integrated governanceboard and operational management groupmeetings. Developing Initiatives for Support in theCommunity had previously used reverse mentoring, whereclients were paired with senior managers to share feedbackon their journey through treatment. Clients were alsoinvited to attend senior management team meetings attimes and were involved in staff recruitment panels.

Forward Leeds had a service user involvement group whereclients were given the opportunity to feedback on theservice they received and identify areas where the servicecould improve. The service reimbursed bus fares to supportclients to attend. At the last meeting in November 2016,nine clients had attended this group. The agenda itemsincluded suggested ways to make recovery visible, whatwas working, what was not working and possible solutions.Examples of changes to service delivery as a result offeedback from this group were the renaming of theRecovery Academy, a direct phone number for theacademy and the availability of more un-structuredactivities such as books, games and jigsaws.

Staff encouraged clients at Forward Leeds to attend theRecovery Academy as part of their recovery journey. Staff inthe Recovery Academy encouraged former clients tobecome peer mentors and training for this role was offered.Peer mentors were visible in the hub reception areas toengage with clients and we observed this during ourinspection. During the inspection, we observed aco-production meeting at The Recovery Academy inForward Leeds. Seventeen clients had attended along withthree peer mentors. A celebration event, volunteers forrecruitment panels and peer mentoring training courseswere discussed. All the group members were encouragedto contribute and one of the group presented a poem theyhad written to the group. Developing Initiatives for Supportin the Community staff developed and managed theRecovery Academy. The sessions delivered in the Academywere co-produced with people with lived experience and




included recovery groups, guitar lessons, musicproduction, and IT support. We also observed ‘You Said,We Did’ boards at all hubs in response to feedbackprovided by clients.

Forward Leeds also designed and consulted on theircomprehensive assessment in conjunction with clients.Once developed, staff tested this with service users andsought their feedback which led to further development ofthe tool.

At the North Yorkshire Horizons hub, staff and volunteerscollated feedback from clients through a comments box inreception and the completion of evaluation forms at theend of group work sessions. Service user forums were inplace and the service involved clients in consultation aboutservice delivery and pilot projects.

At the Calderdale Recovery Steps hub, clients were able toprovide feedback via social media sites such as Facebook.Staff also encouraged service users to complete an annualsatisfaction survey.

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

Access and discharge

Forward Leeds offered treatment to adults 18 years andolder who were misusing substances. They also offeredprovision for young people who used substances agedbetween 10 and 18 years of age. The Calderdale RecoverySteps service was accessible to residents of Calderdale whowere aged 21 and over and had a substance misuseproblem. North Yorkshire Horizons supported residents ofNorth Yorkshire over 18 years of age who misused drugs orwere a harmful or dependent drinker.

On the 6th December 2016, 395 adult clients were in activetreatment at the Scarborough hub and 223 at theNorthallerton hub. All clients were seen within the targettime of three weeks to access treatment. Across the NorthYorkshire Horizons services, the proportion of clientsleaving treatment within 12 weeks of referral was below thenational average for all substance types.

At the time of our inspection, there were 762 clientsaccessing the Calderdale Recovery Steps service. Theservice was meeting targets for clients accessing treatment.

Clients waiting over three weeks for their first interventionwas below the national average for all substances. Thenumber of clients in treatment for alcohol and/or drugmisuse had increased slightly but remained below thenational average.

Calderdale Recovery Steps had seen an increase in bothalcohol and drug clients successfully completingtreatment. Clients re-presenting to the service within sixmonths of completed treatment had increased for alcoholusers and reduced for substances users. Opiate clientsspent an average of 4.9 years in treatment with DevelopingInitiatives for Support in the Community: this was abovethe national average of 4.6 years. Early unplanned existsfrom the service for all clients were above the nationalaverage, particularly for alcohol users.

Developing Initiatives for Support in the Community had anengagement policy and this was discussed with clients attheir initial appointment. The policy clearly identifiedexpectations for the client and service. However, from 1September 2016 to 30 November 2016, there were 1570appointments not attended at Calderdale Recovery Stepsout of a possible 2912 appointments. The service offered arobust system for contacting clients who failed to attendappointments which involved a level of support to try tore-engage with clients, via telephone and letters.

Between 1 September 2016 and 30 November 2016, thedata received from Calderdale Recovery Steps serviceappeared to indicate that staff had cancelled 575appointments, affecting 322 clients. We discussed ourconcerns with the data analyst and we were told thesystem was not being used accurately by staff to reportactual cancellations. We examined the data with the dataanalyst and found that the appointments had beenre-arranged, not cancelled. The service acknowledgedfurther staff training was required to address this. Clientstold us that the service did not always communicatere-arranged appointments in a timely manner.

As at 24 November 2016, 3730 adult clients were in activetreatment across Forward Leeds. According to thediagnostic outcomes monitoring executive summary,between 1 July 2016 and 30 September 2016, ForwardLeeds was performing better than the national average forclients starting treatment interventions within three weeks.All clients waited less than three weeks to start treatmentinterventions for opiates, alcohol and opiates and




non-opiates. Commissioners told us that DevelopingInitiatives for Support in the Community and ForwardLeeds had consistently improved the waiting times forclients starting treatment each quarter.

We did not always see that clients were seen in a timelyway by the recovery coordinators in Forward Leeds. For twoclients, including one prison release and one who hadpreviously dis-engaged from treatment, there was a delaybetween the comprehensive assessment and the firstappointment with the recovery coordinator of betweenseven and nine weeks. Developing Initiatives for Support inthe Community had set targets that clients should be seenwithin three weeks and retained in treatment for the first 12weeks at a minimum. These clients had been seen by theclinical provider during this time, however the delay inaccessing recovery support could have impacted theirtreatment journey. Managers informed us that clientsreleased from prison were classed as vulnerable andshould receive additional support. We did not see anydelays in accessing treatment at the other services.

The most recent Forward Leeds performance summarydemonstrated that there had been 750 successfulcompletions up to the end of October 2016. The target forthe service was 1082 by the end of December 2016. Whilstperformance had improved month on month since July2016, it remained below the level required to meet theannual target by December 2016. The planned exitperformance for the young people’s service was 94% inOctober 2016. The Public Health England adult activityreport showed that between 1 April 2016 and 30 September2016, Forward Leeds had made improvements in thenumber of clients successfully completing treatment,except for those clients using both opiates and alcohol. Thediagnostic outcomes monitoring executive summaryshowed that, up to 30 September 2016, Forward Leedsremained below the national average in comparison toother local authority services.

As of the 30 September 2016, the average length of time intreatment across Forward Leeds was 3.1 years. This waslower than the national average of 4.7 years. DevelopingInitiatives for Support in the Community with otherpartners in Forward Leeds continued to focus on reducingthe length of time clients were in treatment and increasethe number of clients leaving the services in a planned way.Managers told us that they focussed on working withclients on planning for discharge at the beginning of their

treatment. This was evident for the new people startingtreatment in the records that we reviewed. However, two ofthe 24 records that we reviewed were for clients who hadbeen long-term opiate using clients that had been stablefor some time on low levels of methadone. We did not seediscussions in those records on future planning anddischarging from the service.

Clients, relatives and carers told us that appointments atForward Leeds were often cancelled. We observedcomplaints and client feedback about cancelledappointments. Managers told us that they would attemptto cover all appointments rather than cancel them duringtimes where staff were absent from work, but that this wasnot always possible. Managers told us they would alsomake contact with clients to discuss the appointmentcancellation with them and discuss any additional support.Managers told us that appointments were cancelled lessfrequently since the staffing levels in the service hadbecome more static, following a period of transition forstaff after the new contract was awarded.

Clients and staff commented that sometimes theappointments over-ran which frustrated clients. Managerstold us that this was often due to recovery workers trying tosee other clients who had attended late and they wereworking with staff to see clients in the allocatedappointment slots. Appointment availability wasmonitored and discussed in the partnership forums.

In Forward Leeds, we reviewed records of clients who wereattending for their prescribing appointments, but notattending their appointment with the recoveryco-ordinator. Staff did not always attempt to co-ordinateappointments with the clinical staff to encourageengagement with the recovery element of their treatment.Following the inspection, the provider submittedinformation to show this was not always the case. Theprovider stated that out of 898 planned appointments forMarch 2017 in Forward Leeds, 826 had an appointmentwith their recovery co-ordinator and clinician on the sameday. Managers told us that the positive engagement policywas being reviewed at the time of inspection, which wouldsupport staff in the Forward Leeds partnership to worktogether to address non-engagement. North YorkshireHorizons were reviewing the effectiveness of their newpathway to re-engage high risk clients. This pathway hadbeen developed in conjunction with the provider of clinicalservices in the area.




The facilities promote recovery, comfort, dignity andconfidentiality

All hubs had sufficient rooms to deliver care and treatment,including group-work rooms, one to one rooms, clinicrooms and space for urine testing including toilet facilities.

The Forward Leeds service had one electrocardiogrammonitor that was shared across all three hubs. Bloodpressure monitors and breathalysing machines were not inall clinics, but shared between the clinics and staff in eachhub. Staff told us that this meant they may have to leavethe appointment to get the equipment if it was notsomething that was pre-planned. They also told us thatthere had been occasions where they had wanted tobreathalyse a client but a machine had not been availableso the client was not breathalysed.

Forward Leeds also had a separate ‘Recovery Academy’that all clients across Leeds could access. It was a place forthose clients who were in recovery and offered a widerange of recovery focussed activities and structured groupwork. In Scarborough, DISC had established a second handshop that enabled clients to work as volunteers and gainsome work experience as part of their recovery. At SapphireHouse, volunteers ran a social enterprise that sold secondhand furniture to the public. Developing Initiatives forSupport in the Community had allocated some of thespace to a local man from the community who sold bric abrac items. Developing Initiatives for Support in theCommunity volunteers also operated a café from SapphireHouse which was open to the public.

In Forward Leeds, the rooms for one to one key workingappointments had a glass panel on the doors that staff andother clients could see through. This was also the case atthe Northallerton hub. The provider told us this was due tohealth and safety reasons in case of incidents ofchallenging behaviour.

The clinic rooms at Forward Leeds also had this glass panelin the door but most of these had been covered usingpaper. Managers told us that this was a temporary measurewhilst the service was waiting for the frosting on the glassto be completed. However, the clinic rooms at Irford Houseand two of the clinic rooms at Kirkgate did not have theglass panel covered at all. Staff told us that service userswould on occasion need to partially undress for physicalhealth examinations, including electrocardiogrammonitoring. There were no privacy screens around

examination couches either. This would mean service usersprivacy and dignity could be compromised as people wereable to see through the glass panel to the examinationcouches.

At the Northallerton hub confidential discussions betweenstaff and clients could be overheard in client rooms. Stafftold us that the confidentiality of discussions was anongoing issue in all the Forward Leeds buildings and theHalifax hub of Calderdale Recovery Steps. This was on thelocal risk register and appropriate actions identified. Stafftold us that they made clients aware of the issue. Managersalso confirmed that they had contracted acoustic engineersto address this at all the hubs and the work was stillongoing.

Key information was provided at all sites includinginformation on local advocacy services, safeguardingcontact information, posters on ‘why we ask diversityquestions, how to complain and opening times. There wasadequate signage, leaflets and posters displayed in thehubs giving information on alcohol and drug-related harmand how to access local services.

Meeting the needs of all clients

All hubs in Forward Leeds and the Halifax hub at CalderdaleRecovery Steps were fully accessible for people with adisability or a physical impairment. Each hub had acompleted and up to date disability access audit.

The services aimed to offer equitable access for all clientsregardless of geographical constraints, with the location oftheir hubs. Forward Leeds also offered treatment andsupport from three GP hubs and some services providedaccess to treatment and support in their local GP surgeries.

All hubs opened from 9am to 5pm Monday to Friday. TheForward Leeds service had late night opening on Tuesday,Wednesday and Thursday, where it opened until 7pm forclients that were unable to attend during the day. IrfordHouse was also open until 8.30pm on Tuesdays as it hosteda mutual aid group. The Northallerton and Scarboroughhubs opened late one night per week, as did the Halifaxhub. Staff were also available to facilitate home visits whereclients were unable to attend the hubs, for example due toa physical illness.

The comprehensive assessment on the online client recordsystem gathered information on people’s personal,cultural, social and religious needs. Developing Initiatives




for Support in the Community provided the use oftelephone based interpreting services and informationcould be translated as required. Developing Initiatives forSupport in the Community publicity materials andinformation or advice was published in multiple languages.They maintained a database of all staff who speaklanguages other than English, to supplement externalinterpretation and translation services with internalresources.

The client’s preferred method of communication, such asmail, text or phone call was identified and reviewedregularly. The provider's website used audio software forpeople with visual impairments. Information provided toclients, family members and carers was accessible andcould be provided in easy-read format. However,the Forward Leeds handbook contained a lot of detailedinformation. The provider told us following the inspectionthat this handbook had been developed in conjunctionwith service user groups. Managers told us that staff wouldgo through the client handbook with clients to supportthem with their understanding of the information and thetext.

Developing Initiatives for Support in the Community hadadapted their service delivery to respond to the 2016 NHSAccessible Information standards. The standard aims tomake sure people who have a disability, or sensory losshave access to information that they can understand andany communication support they might need. The onlineclient record system flagged any clients and carers that hadcommunication needs in relation to sight, speech andhearing. Staff then ensured they had access to informationin a way they could understand.

Developing Initiatives for Support in the Community hadadopted the “Browsealoud” system. This ensured websitesand marketing literature were accessible to people withdyslexia, reading difficulties, visual impairments andEnglish Language Learners. DISC were also developing anaccessible communications policy, easy read complaintspolicies and easy read safeguarding policies.

Forward Leeds had a dedicated young people servicewhich offered appointments at home, school or in localcommunity centres. This service also worked with18 to 23year olds if this better met their requirements, due todevelopmental needs, vulnerabilities or involvement withother young people’s services.

Listening to and learning from concerns andcomplaints

Developing Initiatives for Support in the Community had acomplaints policy and all hubs provided information toclients and their carers on how to complain. All receptionareas had a suggestion box for feedback and complaints.Staff told us they encouraged clients to complain if theywanted to and would support them to do so. Complainthandling was included in the staff induction. Complaintswere recorded centrally and reviewed by seniormanagement. All complaints went to the hub manager,who acknowledged the complaint within the five daytimescale. The hub manager identified a relevant partner tocomplete the investigation and to respond to thecomplainant within 20 days. Developing Initiatives forSupport in the Community provided written and verbaloutcomes of complaints to clients informing them of theirrights to appeal. Complaints were reviewed at theintegrated governance board and learning disseminatedthrough team meetings and staff supervision. This wasconfirmed in the meeting minutes that we reviewed.

In the North Yorkshire Horizons hubs, examples of changesin response to complaints were new flooring being laid inthe reception area of the Harrogate site and the provisionof a service in Malton. Staff understood the complaintspolicy and the clients we spoke to were aware of how tomake a complaint, although none had felt the need to doso. However, responses to complaints did not always followthe process of an acknowledgement, apology andexplanation of what they were dong to put the issue rightas outlined in their policy.

Developing Initiatives for Support in the Community hadreceived 98 formal complaints were in the 12 months priorto inspection. Of these, 52 (53%) were upheld. The majorityof the complaints were at the Forward Leeds service, whichis the largest service with over 3500 clients. Between 1September 2015 and 30 September 2016, 62 complaintswere received for Forward Leeds. Forty-two of thosecomplaints were upheld and five were partially upheld. Wereviewed the complaints and compliments spreadsheet forForward Leeds. The complaints information wascomprehensive and included the date of the complaint,how the complaint was received, the date of the response,the level of seriousness, the action taken and the learningidentified. It also recorded whether all the responses werewithin the required timescales. Staff were able to give us




examples of where changes had been made a result of acomplaint, such as a review of the clinical administrationsystems where a client had waited some time for aprescription.

Of the 98 complaints received, none had been referred tothe Parliamentary and Health Service Ombudsman.

Developing Initiatives for Support in the Community hadreceived 291 compliments in the 12 months prior toinspection. The North Yorkshire Horizons service hadreceived 181 of these and Forward Leeds had received 52.The compliments referenced staff going that extra mile,helping clients through their recovery and being supportiveto clients in challenging and difficult times. Complimentsreferred to staff as being professional, understanding, andpositive.

Are substance misuse services well-led?

Vision and values

The Developing Initiatives for Support in the Communityvision was to support people to realise their potential andto help them become a contributing member of oursociety. Their mission was to promote social inclusion,which was supported by a charter of values. The valueswere fairness, integrity, safety, quality and effectiveengagement. At the time of inspection, DevelopingInitiatives for Support in the Community were reviewingtheir documented mission, vision and values inconsultation with staff, volunteers and service users. Thiswas five months into the review with an expectedcompletion date of early 2017. Following the inspection,the provider told us that all Developing Initiative forSupport in the Community staff at Forward Leeds hadattended vision, mission and values consultations. Six staffat Forward Leeds said they could not recall being involvedin these consultation events. The provider had also paid anexternal consultant to analyse where their services wouldfit in the future health and social care market.

We observed staff in all roles demonstrating the currentvalues in their approach with clients. Staff we spoke withdescribed behaviours which represented these values,especially those that demonstrated integrity and effectiveengagement. In the Scarborough and Northallerton hubs,the vision and values were displayed on the wall in thereception area.

Staff knew who senior managers were and most staff toldus they felt confident in approaching the operationsdirector and hub managers from Forward Leeds if theyneeded support. Fourteen of the 21 staff we spoke to atForward Leeds told us that senior managers visited theservice. The chief executive officer visited the hubs duringthe inspection. In the Halifax hub, one volunteer told usthey were part of the consultation team looking at thevision, mission and values of the organisation. They told usthis increased their confidence and made them feel part ofthe organisation. Staff also told us they had participated inworkshops and felt part of the organisation’s change.

Good governance

Developing Initiatives for Support in the Community had afive year strategic plan with 13 strategic objectives for 2016to 2017. These were categorised into financial, businessdevelopment, quality and performance, organisationaldevelopment, human resources and communication.Progress towards these was monitored through seniormanagement team meetings, a leadership forum andboard of trustee meetings. An annual planning cycleensured that progress towards these objectives waspresented to the board each year, followed by thedevelopment of priorities for the following 12 months. Eachservice had a strategic plan which identified six key areas ofperformance that fed into the provider's overarching plan.

In the two years prior to inspection, Developing Initiativesfor Support in the Community had undergone significantchanges in leadership and service delivery with a numberof transitions of staff and resources. Each service contracthad an integrated governance and partnership board andan operational director. These fed into the organisationsintegrated governance board, which reported to the ChiefExecutive Officer. The Chief Executive officer chaired theForward Leeds partnership board meeting, attended theCalderdale integrated governance board meetings, andattended every other North Yorkshire Horizons integratedgovernance board meeting. A quality lead within eachservice reported to the quality manager at head office toensure clear reporting lines.

Developing Initiatives for Support in the Community aimedto retain 95% of all contracts and were meeting thistarget. They had achieved their growth targets andexpanded their service delivery over the previous twoyears. Following this period of growth, the seniormanagement team were keen to ensure they implemented




effective and consistent processes across all services. At thetime of inspection, Developing Initiatives for Support in theCommunity were developing two electronic systems tosupport service delivery. One was a staff intranet and theother was a staff electronic system which would contain ahuman resources self-serve system, the currentmanagement information system, safeguarding andincident information. Both systems were due to be in placeby March 2017.

Developing Initiatives for Support in the Community werethe lead contract holder for the Forward Leeds, NorthYorkshire Horizons and Calderdale Recovery Steps services.They subcontracted and worked in partnership with otherlocal providers to deliver the care and treatment for peoplerequiring support for substance misuse. All these serviceswere underpinned by comprehensive local governancestructures to ensure an integrated approach to servicedesign and delivery. Forward Leeds was the second largestsubstance misuse service in the country and involved acomplex consortium arrangement of five providers withDeveloping Initiatives for Support in the Community beingthe lead contract holder.

These integrated governance structures included thePartnership Board (strategic management, high levelperformance and finance), the Integrated GovernanceBoard (clinical Governance, high level incidents, deaths inservice and complaints), and the operational managementgroup (operational issues, health and safety, quality,performance and risk). The integrated governance boardand the operational management group had four subgroups: pathways, audit strategy, safeguarding and clinicalpractice. We observed meeting minutes and notedrepresentation from all partners with communicationbetween these structures and below to the staff teams.Systems and partnership working at all levels appearedcohesive and seamless, with a firm partnership approach.

Policies and procedures used by the Forward Leeds servicewere agreed at the integrated governance board. Weobserved a presentation cascaded to staff so they wereaware of which policies were used in Forward Leeds, bywhom, and for what. Forward Leeds had a matrixmanagement approach to supporting staff. This was aframework that was established to underpin the ForwardLeeds partnership agreement for managing staff betweenall providers within each hub. A protocol clarified the roles,

responsibilities and accountabilities of each organisationand reflected the collaborative approach. It also identifiedtheir role with regard to reporting absence, supervision andreporting incidents and complaints.

Forward Leeds was the second largest substance misuseservice in the country and involved a complex consortiumarrangement of five providers with Developing Initiativesfor Support in the Community being the lead contractholder. The provider had put many governancearrangements in place to ensure oversight with regard tothe contract management and service delivery in ForwardLeeds. We saw good examples of partnership working in allthe services we visited. However, concerns in some of thejoint systems led by other partners in Forward Leeds wereidentified. These included infection control, clinical wasteand the location of keys out of hours for prescriptionstorage and management. Systems to manage mandatorytraining compliance and to ensure training was delivered tostaff were not effective. Mandatory training compliance waslow and the training data was inaccurate.However, Developing Initiatives for Support in theCommunity had plans in place to address this and hadrecruited additional training staff centrally in theorganisation. Developing Initiatives for Support in theCommunity were also introducing a new electronic systemto ensure there was more accurate monitoring of trainingdelivery and compliance.

Systems were in place to monitor complaints and incidentsacross the service and these were investigated whereappropriate. Lessons learnt and best practice wascascaded to the teams via team meetings. Thisinformation, as well as client and staff feedback was usedto inform service provision.

Each service had a risk register and Developing Initiativesfor Support in the Community maintained anorganisational risk register. This followed the CharityCommissions guidance and was rated red, amber andgreen to reflect levels of concern and action taken tominimise risk. Items were categorised into financial,governance, operational and environment. Managers wereable to submit items to the risk register and actions toaddress or mitigate the identified risks were identified. Forexample, Developing Initiatives for Support in theCommunity as the lead contract holder for Forward Leedsidentified poor performance on the National DataTreatment Monitoring System as a risk to their business. To




address this, they had developed a performance strategy,completed engagement events with all teams, reviewed theperformance of Forward Leeds and reviewed the treatmentpathways.

Sub-contracts were agreed with partners and processeswere established for monitoring performance within eachservice. Commissioners set local targets in line with localneed and strategy. Performance outcomes were discussedat service operational management groups, integratedgovernance boards and partnership board meetings. Staffcompleted weekly and fortnightly performance reportswhich were cascaded to management and staff teams. Weobserved ‘trackers’ that staff used to support them inmeeting these targets. These were based around servicekey performance indicator measures, including successfulcompletion and treatment outcome profiles. Operationsmanagers received weekly update reports on theperformance of the service against key performanceindicators. Each service submitted data to the NationalDrug Treatment Monitoring System, overseen by the datamanager at head office. Performance was an improvingpicture for the service on their targets including treatmentoutcome profile targets, successful completions, and waittimes to access treatment. Developing Initiatives forSupport in the Community benchmarked performanceagainst the national average and similar services and eachservice had a performance improvement plan.

Performance monitoring was used to improve delivery. Anexample of this was within North Yorkshire Horizons, it hadbeen identified that waiting times were starting to reachthree weeks. In response, staff reviewed caseloads andanalysed new referrals, following which waiting times wereback on target. Within Forward Leeds, a collaborativeapproach was adopted with partner organisations, withactivity targets for each provider agreed in consultation tohelp drive successful completion outcomes.

Quality was a standing agenda item at all governancemeetings. Quality managers maintained a quality auditschedule, which included a twice yearly quality audit perhub against the CQC key lines of enquiry. Each hubundertook a self-assessment against the CQC key lines ofenquiry every quarter. Developing Initiatives for Support inthe Community had carried out 29 quality visits acrossForward Leeds, North Yorkshire Horizons and CalderdaleRecovery steps in the 12 months prior to inspection. Thesewere conducted by senior managers and internal quality

auditors who were not directly located at the sites. Of theseaudits, 22 were infection control, six were quality auditsand one was a health and safety audit. Each site alsoundertook local audits with the involvement of staff withinthe service, although they were not always effective inidentifying issues. These audits were not alwayscompleted, for example, at Irford House some of thequarterly audits were not completed due to staffing issues.

Developing Initiatives for Support in the Community had 64policies in place to support service delivery. At the time ofinspection, four of these were subject to review with workongoing. Policies included sickness absence management,performance management and code of conduct. DISC hadbusiness continuity plans in place for each service.

Leadership, morale and staff engagement

Managers at Forward Leeds reported that there had been ahigh turnover of staff following the tender process, howeverthey felt staffing was now consistent with a much lowerturnover rate in comparison to the previous year. Staffreported that there remained some vacant posts and thatpositions were not always filled when staff left. Managers atForward Leeds explained that this was due to the reducedbudgets and reallocation of funds for staff to positions inthe system where there was increased client activity.However, staff told us that the reasons for these vacantposts was not always communicated.

In North Yorkshire Horizons, staff told us they were happy intheir roles, describing good morale and relationshipswithin the team. The Chief Executive Officer was aware thatstaff morale had been low at the Scarborough hub due tolow staff numbers and difficulty recruiting in that area. Theoperational director for that area had been working withstaff to improve morale and using agency staff to covervacant posts. Staff felt morale had improved over the yearas staffing levels increased and caseloads became moremanageable.

In the Halifax hub, staff consistently told us about theirpositive experiences of working within DevelopingInitiatives for Support in the Community. Staff felt valued,listened to and enjoyed working as part of a team. Wereceived four comment cards from staff, all of which werecomplimentary about their service and colleagues.

The staff code of conduct and whistleblowing procedurewas included within the staff induction. Despite figuresshowing that only half of staff had completed the




induction, all staff we spoke with were aware of thewhistleblowing policy and said they would feel confident atusing it. The staff we spoke with felt they would not need touse the whistleblowing policy as they felt confident inapproaching the managers directly to raise concerns. Apolicy and procedure was in place to support and guide allstaff should they experience bullying or harassment atwork.

In Forward Leeds, all the staff we spoke to said that theywere proud of their work with clients and that they werepassionate about their job and enjoyed it, despite it beingstressful at times. Staff attributed the stress to the volumeof work, particularly in the active recovery teams wherecaseloads were approximately 80 per recoveryco-ordinator. However, most staff told us they feltsupported by managers during these times. In the NorthYorkshire Horizons service staff reported caseloads weremanageable, that they were happy in their role and hadgood relationships within their teams.

Almost all staff said they felt valued by the organisation andthat they were able to feedback into the development ofservices. Staff felt that Developing Initiatives for Support inthe Community was committed to identifying andimplementing new learning in order to improve the service.

Developing Initiatives for Support in the Community’s staffsurvey December 2015 identified that 86% of respondentsstated that they had an excellent relationship with their linemanager citing line managers were approachable,understanding and supportive. At the time of theinspection, Developing Initiatives for Support in theCommunity had just launched the 2016 staff annual surveythat staff could complete anonymously via an on-linesurvey site. The senior management team identified thatlinks between staff and themselves could be improved andwere undertaking a number of executive roadshows withstaff at the time of inspection. These were held quarterlyand the aim was to review progress, gather feedback andanswer questions staff had about the service provision.

Developing Initiatives for Support in the Community hadresponded to feedback from the annual staff survey andInvestors in People report that recognition and reward ofstaff was an area for development. They had benchmarkedstaff pay against other providers and some pay scales werebeing reviewed.

We saw evidence that staff could progress through theservice, with staff moving up into management positionsfrom other front-line staff roles similar to recoverycoordinator roles. Peer mentors and volunteers had alsomoved into paid employment with Forward Leeds.

In January 2016, Developing Initiatives for Support in theCommunity had been awarded the gold standard in theNorth East Better Health at Work Award. As part ofthis, Developing Initiatives for Support in the Communityhad recently launched a staff wellbeing mental health firstaider initiative. This involved a lead staff member and anumber of deputies receiving accredited training onsupporting staff who were encountering depression,anxiety, suicidal thoughts, self-harm or psychosis. The rolewas to provide initial support and refer to other servicesoutside of the organisation. The first staff membercommenced this role the week prior to inspection with aview to this being rolled out across the organisation.

The director of operations provided a point of contact forstaff that were experiencing domestic abuse. This was asupportive role to ensure staff and service usersexperiencing domestic abuse could access financialsupport and a safe place to stay.

Developing Initiatives for Support in the Community hadcontact and support officers for staff to access if theyrequired advice or guidance relating to proceedings,regulations, equal opportunities and other policies. Theyprovided confidential and emotional support andadvocacy, supporting staff in disciplinary and grievanceprocedures. Staff also had access to six counsellingsessions with an external organisation and funding couldbe sought for additional sessions if required.

Commitment to quality improvement and innovation

Developing Initiatives for Support in the Community hadbeen awarded the Investors in People silver award inAugust 2016. The report reflected on the provider’sconsiderable growth over the previous two years, theirappetite for continuous improvement and their widespreaduse of external standards and frameworks. The reportidentified two key areas for development, the reward andrecognition of staff and their opportunities for learning anddevelopment. The management team had devised anaction plan detailing how they would work towardsachieving the gold award over the coming two years.




Developing Initiatives for Support in the Community wereinvolved in the development of the Naloxone programmefor clients in Forward Leeds. Naloxone is an emergencymedication used in cases of opiate overdose. They hadidentified clients at high risk of overdose who wouldbenefit from having Naloxone. Staff had completed thetraining to support clients and family members in the useof Naloxone.

A Forward Leeds Performance Strategy was in place whichhad clear activity targets for all partners, to ensure clearand consistent management approaches aroundperformance. Developing Initiatives for Support in theCommunity had also introduced integrated performancemeetings along with the integrated governance meetingsto review and improve the performance of the service.Managers held weekly panel meetings to discuss individualcases and particular cohorts of clients to support recoverycoordinators to engage clients and help them movethrough treatment. Developing Initiatives for Support in theCommunity had an individual caseload ‘tracker’ for allrecovery coordinators that monitored their performanceindicators, such as when recovery plans, risk managementplans and treatment outcome profiles were due for review.Recovery coordinators received a tracker every fortnightwhich helped them to manage their caseload of clients andmeet the performance targets. As a result, performancehad improved in the last few months.

Developing Initiatives for Support in the Community hadidentified that the Northallerton hub had the highestnumber of alcohol users in women aged 40 and over. Inresponse, they developed an alcohol pathway inconjunction with clients. This was initially ran as pilotproject involving staff from different hubs to share theirknowledge and experience. At the time of inspection, thepathway was running in Northallerton, Selby and Harrogatewith a plan to roll it out across the other hubs. We spokewith clients who felt very positive about the help they hadreceived for their alcohol dependency.

Developing Initiatives for Support in the Community staff inNorth Yorkshire Horizons worked closely with families whowere involved in the family drugs and alcohol court. This

was a problem-solving court approach to improvingoutcomes for children involved in care proceedings. Itoffered an alternative way of supporting parents toovercome the substance misuse, which has put theirchildren at risk of serious harm. The process involvedcoordinating a range of services so that a family’s needsand strengths are taken into account, with everyoneworking towards the best possible outcome for the child.We spoke to one couple who worked with DevelopingInitiatives for Support in the Community and wereattending the ‘through my child’s eyes’ group workprogramme as part of the court approach. They felt it was avery powerful group which helped them to gain insight intothe effects of their behaviour on their child.

In Calderdale Recovery Steps, the service was taking part inthe West Yorkshire finding independence scheme, a pilotscheme offering extended support to clients who are at riskof falling out of treatment. This was commissioned by thenational lottery and if successful it was hoped it would berolled out in other parts of the country.

DISC were committed to gathering input from clients toshape their service and improve the design and delivery.Involvement of people with lived experience was one of theprovider’s performance indicators. Service userinvolvement was demonstrated in discussions in meetingsfrom the partnership board to service level. We sawevidence that Developing Initiatives for Support in theCommunity at Forward Leeds listened to clients andresponded to their feedback.

Managers attended external conferences and forumsincluding the National Data Treatment Monitoring Serviceforum and the Novel Psychoactive Substance forum andconference. In this way, the service inputted into nationalagendas and helped to shape service delivery. The chiefexecutive officer of Developing Initiatives for Support in theCommunity attended the northern meeting of ‘collectivevoice.’ Collective voice includes other chief executives ofsubstance misuse charities and they agree how the thirdsector can influence national policy and priorities withinthe substance misuse field.




Outstanding practice

Developing Initiatives for Support in theCommunity received the Investors in Volunteeraccreditation in April 2015. This is the UK quality standardfor all organisations involving volunteers, it recognisescommitment to providing an all-round volunteerexperience. The provider had a service wide volunteerco-ordinator and each service had dedicated volunteers.Following the inspection, the provider told us that inLeeds, they had also received the Leeds City Councilvolunteering kite mark.

In Forward Leeds, Developing Initiatives for Support inthe Community had implemented one electronic systemthat was accessed by all providers involved in servicedelivery. This allowed staff to maintain contemporaneousnotes about clients and share information across theservice. This provided a more streamlined andco-ordinated service for the client. Developing Initiativesfor Support in the Community used this system toproduce reports to monitor their key performanceindicators and to support staff in managing theircaseloads.

Staff worked with vulnerable and hard to reach groups toensure they could access services. Staff worked withvulnerable and hard to reach groups to support them toaccess services. DISC had adapted their service deliveryto respond to the 2016 NHS Accessible Informationstandards. DISC also ensured their websites wereaccessible for people with dyslexia, reading difficultiesand visual impairments. DISC provided the use oftelephone based interpreting services and their publicitymaterials and information for clients was published inmultiple languages. Developing Initiatives for Support inthe Community had held the Equality North East ‘EqualityStandard Gold Award’ since 2012.

DISC were committed to quality improvement andinnovation, which involved the use of external standardsand frameworks. DISC had been awarded the Investors inPeople silver award in August 2016 and had an actionplan in place to work towards gold standard.

Areas for improvement

Action the provider MUST take to improve

• The provider must ensure that risk assessments atForward Leeds include all identified risks and arereviewed in line with national guidance and theirown policy. The provider must ensure that riskmanagement plans identify appropriate actions tomanage the risks identified.

• The provider must ensure that clients’ privacy anddignity is maintained in all clinic rooms at ForwardLeeds.

• The provider must ensure that staff at Forward Leedsreceive an induction into their role and the service.The provider must ensure that mandatory training isclearly defined for each role and accessible to staffacross all services.

• The provider must ensure that recovery plans atForward Leeds and Calderdale Recovery Steps aredetailed, personalised and reviewed every 12 weeksin line with national guidance and their policy.

• The provider must ensure they have systems orprocess established, to assess and monitor staffcompliance with the Mental Capacity Act 2005. Theprovider must ensure staff understand the Act and itsapplication in practice.

• The provider must ensure that at Forward Leeds,they have sufficient oversight and accountability forall systems and processes to deliver a safe service.The provider must ensure that the role andresponsibilities of all staff are clearly defined andthat staff are suitable skilled with regards to infection

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


control procedures and the management of clinicalwaste. The provider must ensure there are effectivesystems in place to monitor staff compliance withmandatory training.

• The provider must ensure all equipment is clean atthe Kirkgate hub and that all items are identified tobe cleaned on cleaning schedules.

Action the provider SHOULD take to improve

• The provider should ensure that signposting toemergency medicines is very clear and precise toensure staff can quickly access them in anemergency.

• The provider should ensure that staff are pro-activein re-engaging clients who fail to attendappointments. Staff should work in partnership withother providers in the service to maximise clientengagement.

• The provider should ensure a procedure is in placeto manage the risks associated with clients bringingchildren to appointments at the hubs.

• The provider should ensure that all clients are seenwithin identified timescales.

• The provider should ensure that incidents of harmare graded to enable them to identify when anincident has met the threshold under the duty ofcandour.

• The provider should ensure all staff understand theirresponsibilities under the duty of candour.

• The provider should ensure staff have access tosufficient equipment to enable them to delivertreatment interventions.

• The provider should ensure that all staff receivesupport and information through team meetings in atimely manner.

• The provider should ensure that staff feel supportedby the supervision process and that individualobjectives are specific and personalised.

• The provider should ensure that they take aconsistent approach to managing caseloads.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activity

Treatment of disease, disorder or injury Regulation 9 HSCA (RA) Regulations 2014 Person-centredcare

At Forward Leeds and Calderdale Recovery Steps, staffdid not always ensure care and treatment was plannedin a way that reflected individuals preferences andensured their needs were met. Staff did not alwaysdevelop detailed and personalised recovery plans withclients.

This was a breach of Regulation 9 (3) (b)

Regulated activity

Treatment of disease, disorder or injury Regulation 10 HSCA (RA) Regulations 2014 Dignity andrespect

The provider did not always ensure the privacy of theclient at Forward Leeds. Clinic rooms at Irford House andtwo clinic rooms at Kirkgate had glass panels that werenot obscured to those outside the room. There were noscreens or curtains in the room to protect clients’ dignityand privacy during physical examinations.

This was a breach of Regulation 10 (2) (a)

Regulated activity

Treatment of disease, disorder or injury Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

Regulation

Regulation

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


At Forward Leeds, staff did not always fully assess clientrisks or identify action required to mitigate identifiedrisks. Staff did not always review risk as regularly asrequired or complete a risk management plan.

This was a breach of Regulation 12 (2) (a) (b)

Regulated activity

Treatment of disease, disorder or injury Regulation 15 HSCA (RA) Regulations 2014 Premises andequipment

The provider did not always ensure equipment used bystaff and clients was clean. We found unclean equipmentat the Kirkgate hub.

This was a breach of Regulation 15 (1) (a)

Regulated activity

Treatment of disease, disorder or injury Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

The provider did not always ensure systems andprocesses were established and operated effectively tomaintain oversight of service delivery at Forward Leeds.This included staff training, infection control procedures,emergency medicines and the management of clinicalwaste.

The provider did not have a system or processestablished, to assess and monitor staff compliance withthe Mental Capacity Act 2005. Staff did not consistentlyapply the Mental Capacity Act 2005 in practice. Therewas no oversight or assurance that the Mental CapacityAct 2005 was being applied across the organisation.

Regulation

Regulation




This was a breach of Regulation 17 (1) (2) (b)

Regulated activity

Treatment of disease, disorder or injury Regulation 18 HSCA (RA) Regulations 2014 Staffing

The provider did not always ensure that staff weresuitably qualified and skilled to deliver care andtreatment. Staff at Forward Leeds did not always receivean induction to the role and service. Mandatory trainingwas not clearly defined for each role.

This was a breach of Regulation 18 (1)

Regulation




Documents

DISC (Developing Initiatives Supporting Communities ... · Howwecarriedoutthisinspection Tounderstandtheexperienceofpeoplewhouse services,weaskthefollowingfivequestionsaboutevery