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Locations inspected Location ID Name of CQC registered location Name of service (e.g. ward/ unit/team) Postcode of service (ward/ unit/ team) 1-215186182 Turning Tides Recovery Project Turning Tides Recovery Project BN11 2LL This report describes our judgement of the quality of care provided within this core service by Turning Tides Homelessness. Where relevant we provide detail of each location or area of service visited. Our judgement is based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from people who use services, the public and other organisations. Where applicable, we have reported on each core service provided by Turning Tides Homelessness and these are brought together to inform our overall judgement of Turning Tides Homelessness. Turning Tides Homelessness Turning urning Tides Tides Rec ecover overy Pr Project oject Quality Report Delaney House 14 Selden Road, Worthing, BN11 2LL Tel: 01903 680744 Website: www.turning-tides.org.uk/what-we-do/ recovery-project/ Date of inspection visit: 14/05/2019 Date of publication: 11/07/2019 Good ––– 1 Turning Tides Recovery Project Quality Report 11/07/2019

Good Turning Tides Homelessness TurningTidesRecovery Project · 2020. 7. 14. · Locations inspected Location ID Name of CQC registered location Name of service (e.g. ward/ unit/team)

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Page 1: Good Turning Tides Homelessness TurningTidesRecovery Project · 2020. 7. 14. · Locations inspected Location ID Name of CQC registered location Name of service (e.g. ward/ unit/team)

Locations inspected

Location ID Name of CQC registeredlocation

Name of service (e.g. ward/unit/team)

Postcodeofservice(ward/unit/team)

1-215186182 Turning Tides Recovery Project Turning Tides Recovery Project BN11 2LL

This report describes our judgement of the quality of care provided within this core service by Turning TidesHomelessness. Where relevant we provide detail of each location or area of service visited.

Our judgement is based on a combination of what we found when we inspected, information from our ‘IntelligentMonitoring’ system, and information given to us from people who use services, the public and other organisations.

Where applicable, we have reported on each core service provided by Turning Tides Homelessness and these arebrought together to inform our overall judgement of Turning Tides Homelessness.

Turning Tides Homelessness

TTurningurning TidesTides RRececoveroveryyPrProjectojectQuality Report

Delaney House14 Selden Road,Worthing,BN11 2LLTel: 01903 680744Website: www.turning-tides.org.uk/what-we-do/recovery-project/

Date of inspection visit: 14/05/2019Date of publication: 11/07/2019

Good –––

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RatingsWe are introducing ratings as an important element of our new approach to inspection and regulation. Our ratings willalways be based on a combination of what we find at inspection, what people tell us, our Intelligent Monitoring dataand local information from the provider and other organisations. We will award them on a four-point scale: outstanding;good; requires improvement; or inadequate.

Overall rating for the service Good –––

Are services safe? Good –––

Are services effective? Good –––

Are services caring? Outstanding –

Are services responsive? Good –––

Are services well-led? Good –––

Mental Health Act responsibilities and MentalCapacity Act / Deprivation of Liberty SafeguardsWe include our assessment of the provider’s compliancewith the Mental Health Act and Mental Capacity Act in ouroverall inspection of the core service.

We do not give a rating for Mental Health Act or MentalCapacity Act; however we do use our findings todetermine the overall rating for the service.

Further information about findings in relation to theMental Health Act and Mental Capacity Act can be foundlater in this report.

Summary of findings

2 Turning Tides Recovery Project Quality Report 11/07/2019

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Contents

PageSummary of this inspectionOverall summary 4

The five questions we ask about the service and what we found 5

Information about the service 10

Our inspection team 10

Why we carried out this inspection 10

How we carried out this inspection 10

What people who use the provider's services say 11

Areas for improvement 11

Detailed findings from this inspectionLocations inspected 12

Mental Capacity Act and Deprivation of Liberty Safeguards 12

Findings by our five questions 13

Summary of findings

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Overall summaryThe service was last inspected in 2016, at which time wedid not rate independent substance misuse services.Werated Turning Tides Recovery Project as Good because:

• The service was well staffed with a range of welltrained and experienced staff. Staff put into practicethe service’s vision and values. Staff had contact withmanagers at all levels of the organisation, includingthe most senior, who were supportive and visible.

• The service was clean and comfortable with a verygood range of facilities. Effective systems ensuredany issues with the building or facilities wererectified quickly.

• There was a proactive approach to understandingthe needs and preferences of different groups ofpeople, and to ensuring the service met these needs,promoting accessibility and equality. The individualneeds of each client were considered carefully bystaff, ensuring their individual preferences and needswere always reflected in how support was delivered.

• Staff managed risk well using effective systems andprotocols, including clients at risk of relapse. Allclients had holistic, personalised support plans, andwere encouraged to take an active role in their ownrecovery and risk management.

• The organisation did not subscribe to any specificrecovery model and would support any option thatsuited an individual. It also offered a uniquemanaged withdrawal from alcohol programme,designed by the registered manager in partnershipwith colleagues from other disciplines. The servicemanagers advised us that this programme had beenindependently evaluated by a medically qualifieddetoxification specialist, and approved by PublicHealth England.

• Incidents, complaints and safeguarding concernswere monitored to identify where improvementscould be made.

• The community ethos of the organisation was verystrong and effective. The organisation had verystrong community links and a recovery pathway forpeople to move through. Support was available foras long as people needed it.

• The service had excellent links with partnerorganisations and the wider community, offering abroad range of opportunities to clients to engage,build relationships and undertake training,educational or employment opportunities.

• Clients told us they liked the feeling of inclusion, oneexample being the family feeling of Christmas-time,with gifts being exchanged and a full Christmasdinner prepared and eaten together.

• Clients were consulted on all aspects of the runningof the service and participated in staff recruitment.The Partnership and Co-Production Team (PACT),which was a group of clients and ex-clients, weresignificantly involved at all levels of the organisation,including budgets and policy changes, and metregularly with the trustees.

However:

• Although the service had an appropriate MentalCapacity Act policy which formed part of theinduction, not all staff knew or understood thelegislation, how it applied to this service or how touse it appropriately. This may have been becausesome of the staff were quite new.

Summary of findings

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The five questions we ask about the service and what we found

Are services safe?We rated safe as Good because:

• Comprehensive systems ensured the building was safe, cleanand comfortable. Managers and external auditors undertookappropriate reviews and checks. There were processes in placefor ensuring issues were rectified.

• There was enough suitable staff at the service. Staff hadtraining appropriate to their roles, and were well supported.When the service used staff from agencies, managers ensuredthey were familiar to the service, or, if they were new, enoughtime was set aside to provide orientation and support.

• Risk assessments were comprehensive, detailed and regularlyupdated, and staff used recognised assessment tools. Staffworked very effectively with other professionals to ensureclients were kept safe. We saw evidence that clients wereinvolved in their recovery, and encouraged to participate inmanaging their own risks, especially around relapse.

• Each client had a personalised relapse plan, on which theyworked with staff to develop strategies to manage risks andreduce the likelihood of a relapse occurring.

• Where appropriate, clients carried Naloxone, which is atreatment to rapidly reverse the effects of an opioid overdose.All staff, and clients who needed it, received training in the useof Naloxone. Naloxone was also easily accessible in the staffoffice.

• Systems were in place to keep people safe from abuse andharm. Managers had good relationships with the local authorityand the service had a full-time social worker, who supportedclients to build and maintain effective relationships with theirfamily and children.

• Staff managed medicines safely, and followed clear protocols inline with national guidance. Effective systems ensured staffwere competent to administer medicines to clients safely.

• Systems were in place to ensure incidents were managed safelyand the service learned from incidents to improve practice.

Good –––

Are services effective?We rated effective as Good because:

• Each client had a comprehensive, highly personalised supportplan. These were regularly reviewed and evidenced clientinvolvement. Where appropriate, their care-coordinator wasidentified.

Good –––

Summary of findings

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• Staff used a good range of recognised tools to assess andmanage risk, and measure outcomes.

• The service employed a range of professionals to ensure aholistic wraparound service was provided, including mixedcomplex needs workers, a social worker and a dual diagnosisworker.

• Staff followed best practice guidance including NationalInstitute for Health and Care Excellence (NICE) guidance aroundthe management of medicines.

• A training coordinator ensured all staff and volunteers weretrained and competent for their role. Regular supervision andappraisals provided support and the opportunity to discusspersonal development.

• All referrals were considered by a multi-disciplinary team, andno client was left on the streets as a placement option wouldbe identified elsewhere in the organisation, or within a partnerorganisation if the recovery project was not suitable.

However

• Although the service had an appropriate Mental Capacity Actpolicy which formed part of the induction, not all staff knew orunderstood the legislation, how it applied to this service or howto use it appropriately. This may have been because some ofthe staff were quite new.

Are services caring?We rated caring as Outstanding because:

• There was a strong, visible person-centred culture. Staff treatedclients with dignity, kindness and respect. They provided aholistic service which met the totality of clients’ needs. Eachclient had a key worker with whom they had plenty of one toone time

• Support and treatment was highly personalised. Staff workedhard to empower clients to manage their own recovery andsignposted them to other services as required.

• Clients told us that they felt staff cared about them and thatthey felt they mattered. Clients said staff made time for themwhen they needed it.

• Staff recognised the importance of building and maintainingsupport networks in the community and they were very strongin supporting people to do this.

• Staff and clients knew how to raise concerns and wereconfident to do so if they needed to.

Outstanding –

Summary of findings

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• Staff worked hard to ensure clients were involved in their careand treatment, offering a wide range of opportunities for themto have their say, such as meetings, feedback forms andsurveys.

• A charter created for clients by clients, and an associated staffcharter, set out agreements about how everyone should treateach other.

• Clients told us they liked the feeling of inclusion, one examplebeing the family feeling of Christmas-time, with gifts beingexchanged and a full Christmas dinner prepared and eatentogether.

• Staff recognised that relapse was part of recovery and treatedclients in a respectful non-judgemental way when theyrelapsed.

• The partnership and co-production team (PACT), which was agroup of current and ex-clients was involved in every aspect ofrunning the service, including budgets, policy changes, servicereviews and audits.

• Clients participated in recruiting new staff, includinginterviewing and training.

Are services responsive to people's needs?We rated responsive as Good because:

• The organisation encompassed a full recovery pathway asclients’ needs changed. Clients were fully supported by aninclusive, wraparound service which met the totality of theirneeds, and continued to do so for as long as necessary.

• The multi-disciplinary team consisted of a good range ofprofessionals to ensure diverse and complex needs were fullymet.

• The service had excellent relationships with partner agenciesand the wider community in general. A broad range of activities,fellowships, groups, social events and other services offeringemployment, training and education opportunities wasavailable to clients.

• The service was comfortable and well maintained with a verygood range of facilities, including a family room where clientscould build and maintain healthy relationships with theirchildren, with the full support of a qualified social worker. Eachclient had their own room which they could personalise as theywished.

• Clients had access to a very wide range of activities, communityservices and support. The service had excellent links with thecommunity, and provided education, training and workopportunities.

Good –––

Summary of findings

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• Staff gave new clients a range of information on admission. Thisinformation was also available in communal areas. Key workersand peer buddies were assigned to each new client to helporient and support them.

• The service had a very inclusive admissions policy and therewas a proactive approach to understanding the needs andpreferences of different groups of people, and to ensuring theservice met those needs, promoting accessibility and equality.

• Staff welcomed complaints as opportunities to resolve issues,to learn and improve the service provided.

Are services well-led?We rated well-led as Good because:

• Managers had the skills, experience and motivation to do theirjobs well. The organisation operated with a minimalmanagement structure, and managers at all levels, includingthe trustees, were visible, accessible and supportive.

• Managers were provided with specific training, and annualaway days for all staff ensured there was integration across theorganisation and staff at all levels felt their voice was heard.

• A clear meetings structure ensured that learning andinformation was cascaded appropriately through theorganisation. All staff we spoke with were clear about theorganisation’s vision and values and were aligned to them. Staffat all levels had the opportunity to contribute to changes andthe way the service was run. This was evident in the wayservices were delivered.

• Staff were happy in their roles, were well supported and hadaccess to their own support services if they needed it, such ascounselling and occupational therapy. Staff also attendedmonthly reflective session facilitated by an external counsellor.

• The service had management systems in place to capture andcollate various types of information including feedback andcomplaints, incidents, safeguardings and client outcomes. Thiswas then analysed to see where improvements could be made.

• A range of internal and external targets and key performanceindicators were used to regularly monitor and review theservice.

• A risk register was maintained, ‘rag’ rated (given a red, amber orgreen priority rating) and regularly reviewed.

• Service managers had developed effective joint-workingarrangements and information sharing protocols with a widerange of other professionals and stakeholders. The inclusive,community ethos of the organisation was very strong andeffective.

Good –––

Summary of findings

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• Service managers strove to be innovative, and participated inseveral research and learning groups to ensure services forpeople with substance misuse and homelessness issuesimproved across the local area.

• The service offered a unique managed withdrawal from alcoholprogramme, designed by the registered manager in partnershipwith colleagues from other disciplines. This was the onlyprogramme of its kind in the country, and service managersadvised us that this programme had been independentlyevaluated by a medically qualified detoxification specialist, andapproved by Public Health England.

Summary of findings

9 Turning Tides Recovery Project Quality Report 11/07/2019

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Information about the serviceTurning Tides Homelessness recovery project is aresidential recovery service for single homeless men andwomen with drug and/or alcohol addictions. The servicedoes not provide detoxification, but works with partneragencies, including local substance misuse partnerservice Change Grow Live (CGL) who provide servicessuch as detoxification and medical monitoring. CGL wasnot inspected during this inspection. The recovery serviceis run by Turning Tides Homelessness, which is acommunity led homelessness organisation, aiming tosupport individuals to overcome their addictions and liveindependent lives.

Most referrals are made via the Turning TidesHomelessness day centre, but referrals are also made bypartner agencies such as CGL, the probation service andlocal authority commissioners. Clients need to bemotivated to make positive life changes and committedto engaging positively with the service. The projectadopts both harm minimisation and abstinence-basedinterventions to integrate clients back into thecommunity. Clients can stay at the service for a maximumof 2 years.

The project is staffed 24 hours a day with a minimum oftwo staff on duty at any given time. All clients have theirown room, with nurse call facilities in each room, with theuse of shared communal areas including lounges, a large,fully stocked kitchen and a small gym.

Clients make a financial contribution to their stay at theservice through their housing benefits. At the end of theirtreatment clients are supported into independentaccommodation in the community or in one of theTurning Tides Homelessness community houses, withcomprehensive support for as long as they need it.

The service was last inspected in August 2016and met allthe requirements of the Health and Social Care Act.Turning Tides Homelessness is registered to provide:accommodation for persons who require treatment forsubstance misuse for up to 25 adults. At some point for ashort period prior to this inspection, the service admittedone more client than their registration permits. This wasan oversight on the part of the service and this has beenfully rectified, and the service has committed to applyingto increase capacity.

The service has a registered manager.

Our inspection teamThe team that inspected the service comprised of oneCQC inspector, one assistant CQC inspector and onespecialist advisor who was a nurse with experience ofworking in substance misuse services.

Why we carried out this inspectionWe undertook an unannounced, comprehensiveinspection of this service as part of our routineprogramme of inspecting registered services.

How we carried out this inspectionTo fully understand the experience of people who useservices, we always ask the following five questions ofevery service and provider:

• Is it safe?• Is it effective?• Is it caring?

Summary of findings

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• Is it responsive to people’s needs?• Is it well-led?

Before the inspection visit, we reviewed information thatwe held about the location.

During the inspection visit, the inspection team:

• carried out a tour of the building, including the staffoffices, kitchen, communal areas, the garden and aclient’s bedroom

• interviewed the registered manager, the servicemanager and four members of staff

• spoke with eight current clients• looked at eight client care and treatment files,

including medicines records• observed a handover meeting• looked at policies, procedures and other documents

relating to the running of the service• looked at records relating to the running of the service

including incident and complaints logs

What people who use the provider's services sayFeedback from people using the service was generallypositive. Clients we spoke with felt that the staff caredabout them and their recovery. One client told us theservice was their safe space, and another told us theservice had saved their life. Clients told us they felt safe,and that the property was clean and well maintained.

However, some clients we spoke with felt that the ‘houserules’, which were detailed in the agreement signed by allclients on admission, were not always followed, and thatstaff did not employ a consistent approach in dealingwith this.

Areas for improvementAction the provider SHOULD take to improveThe provider should ensure all staff have appropriateMental Capacity Act training.

Summary of findings

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Locations inspected

Name of service (e.g. ward/unit/team) Name of CQC registered location

Turning Tides Homelessness Turning Tides Recovery Project

Mental Capacity Act and Deprivation of Liberty SafeguardsThe service had an appropriate mental capacity policywhich staff were aware of. Staff ensured that clientsconsented to care and treatment and were involved indecisions, that this was assessed, recorded and reviewed ina timely manner.

Staff received training in the Mental Capacity Act as part oftheir safeguarding training. However individual members ofstaff’s knowledge of the legislation and their duties aroundmental capacity was variable. This may have been becausesome of the staff were quite new.

Turning Tides Homelessness

TTurningurning TidesTides RRececoveroveryyPrProjectojectDetailed findings

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* People are protected from physical, sexual, mental or psychological, financial, neglect, institutional or discriminatoryabuse

Our findingsSafe and clean environment

• The service was in a large property near the seafront. Ithad communal spaces including a lounge, a familyroom, a kitchen, a garden with a designated smokingarea with shelter and a heater, designated quiet areaand a pond, a gym, a dartboard, an arts and crafts roomand private spaces for meetings or confidentialconversations.

• The property was very clean and comfortable at thetime of the inspection. It felt homely and calm, with staffproviding a visible but inconspicuous presence.

• Clients were responsible for keeping the house clean,and agreed a rota for the chores.

• Each client had their own bedroom which was furnishedcomfortably, and clients could personalise as theywished. The service was available to both men andwomen so referrals for vacant bedrooms would includean assessment of whether the available room wassuitable based on a variety of factors, includingconsideration of the gender mix.

• Staff carried out regular health and safety checks of thebuilding and any issues identified were logged on themaintenance spreadsheet, which was RAG rated. Theorganisation had three maintenance staff members,shared with other Turning Tides properties, who metweekly with the service manager to discuss, prioritiseand update the spreadsheet. Where responsive orplanned work to the property was of a specialist nature,outside contractors were employed.

• Other checks carried out regularly by outsidecontractors included fire risk assessments, fire brigadecompliance and legionella. Managers completed regularcontrol of substances hazardous to health (COSSH)audits, fire evacuation drills and checks of the nurse callsystem.

• The service had fire zones and clear instructions onwhat to do in case of an alarm. Regular fire drills wereundertaken.

Safe staffing

• The service had enough skilled staff to meet the needsof clients. There were two recovery staff on all day andone at night. In addition, the service manager anddeputy manager worked all day, including one day atthe weekends. The lone night worker had access to theon-call person and could call on other Turning Tidesservice staff for assistance if needed.

• The staff team included residential substance misuseworkers, a social worker, a dual diagnosis worker and amental health worker. The local GP practice specialisedin providing medical support to homeless people withsubstance misuse issues, and worked closely with theservice.

• The service had a low staff turnover and low levels ofsickness absence. Relief workers employed by TurningTides could be used to cover shifts if needed, andoccasionally agency staff were used, usually at night.Regular agency staff were used to ensure continuity, andany new agency worker was asked to come in one hourbefore their shift started so they could be inducted andoriented to the service.

• Turning Tides had a full-time training coordinator, whowas responsible for ensuring all staff training was up todate. They were also responsible for sourcing, arrangingand evaluating additional specialist training.

• All new staff had an induction, which was a mixture ofonline training, classroom taught and shadowing.Ninety-six per cent of staff had completed mandatorytraining requirements at the time of our inspection.

• Specialist training was also provided according to theneeds of the client group. Examples of recent specialisttraining provided to staff were trauma training andprevention of suicide.

Assessing and managing risk to patients and staff

• Staff completed an initial assessment with potentialclients to ensure the service was the most appropriateplace for their recovery. This assessment establishedthat the client had the motivation and desire to engagewith the service and improve their life.

Are services safe?By safe, we mean that people are protected from abuse* and avoidable harm

Good –––

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• Following the initial screening assessment by a seniorproject worker, an assessment of key areas wasundertaken by members of the team, includingoffending history, motivation and responsibility,physical health, mental health, substance misusehistory, housing and expectations.

• The service used recognised risk assessment tools, suchas CESI, a psychological and social profiling tool fromthe Texas Institute of Addictive Behaviour, and HostelOpiate Overdose Risk Assessment Tool (HOORAT)

• For clients admitted for treatment with alcohol misuseissues, the Clinical Institute Withdrawal Assessment forAlcohol (CIWA-Ar) was used. This is a recognised andvalidated tool, and is a ten-item scale used in theassessment and management of alcohol withdrawal.Where appropriate a Severity of Alcohol DependenceQuestionnaire (SADQ) was undertaken. This is a short,self-administered questionnaire designed by the WorldHealth Organisation to measure severity of dependenceon alcohol.

• A treatment plan was negotiated and agreed withclients. The service did not expect clients to follow anyspecific treatment plan, instead provided the flexibilityto support whichever treatment plan was best suited tothe individual.

• Each client had a relapse plan, which was individual tothem. Relapse plans reflected an individual’s triggersand likelihood of relapse. Staff worked with clients tocreate risk management strategies to avoid relapsing.After a relapse, staff would work with clients to ascertainwhy it happened, work out how to reduce the risk of ithappening again and put risk management strategies inplace.

• Where appropriate as part of their agreed support plan,clients underwent drug and alcohol testing. This was tomeasure recovery and identify risk of relapse.

• Risks for each client were considered at twice daily staffhandovers, and rag rated so that staff starting their shiftknew if any clients had elevated risks, and anyadditional checks or support were agreed. Riskassessments were subject to full review at leastquarterly or more often if necessary.

• The risk of historical conflicts between clients emergingin the service were well managed by the clients’ charter

and the culture of respect and harmony staff workedhard to create. Where there were conflicts clients wereencouraged to manage these constructively and staffwould mediate.

• Where appropriate, clients carried Naloxone, atreatment to rapidly reverse the effects of opioidoverdose, and clients were trained by CGL in the safeuse of it. All staff were also trained in the use ofNaloxone and supplies were freely available in the staffoffice to avoid delays in administering.

Safeguarding

• The service had a clear safeguarding policy which staffwere aware of.

• The service had a safeguarding lead who was also theorganisation’s safeguarding trainer. The trainingprogramme was a full day and was aligned to thestandards of the local authority.

• The safeguarding lead supported the local authority toestablish the local Adult’s Safeguarding Board’s multi-agency audits, which helped to improve safeguardingpractice across the county.

• All staff had safeguarding training as part of theirinduction and then regular refreshers.

• Staff worked effectively within teams, across servicesand with other agencies to promote safety includingsystems and practices in information sharing.

• The service had a full-time social worker who liaisedclosely with the local authority regarding anysafeguarding concerns. The local authority hadallocated two named social workers to the service forcontinuity.

• Staff demonstrated understanding of how to spot anysafeguarding concerns and that they knew how toreport them.

• Safeguarding was one of the items reported on to thesenior management team and the trustees in quarterlyquality reports.

Staff access to essential information

Are services safe?By safe, we mean that people are protected from abuse* and avoidable harm

Good –––

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• All essential information was held electronically, andeach staff member had their own password protectedaccess. Some basic information was still maintained onpaper, but records were identical to those on thecomputer system.

• Each client’s paper file had a front sheet which hadessential information for staff to see at a glance.

• The service had enough computers for staff to use asthey needed to, and they could access emails on theirmobile phones.

• All policies, procedures and other organisationdocuments were stored on a shared drive which staffhad access to.

• The electronic system tracked which reviews andupdates were needed, flagging these to servicemanagers if they were overdue.

• Staff were trained in using the systems, and supportedon an on-going basis by service managers and asystems administrator.

Medicines management

• The service adhered to NICE best practice guidelinesaround the management of medicines.

• On admission to the service, clients gave all theirmedicines to staff, who would then liaise with theclient’s GP for a medicines review.

• All medicines were kept in securely locked cupboards inthe staff office. Each client had their own individuallocker. Staff audited medicines weekly.

• The controlled drugs were kept in a separate, lockedcupboard which was appropriate for the purpose. A logwas kept for the controlled drugs which was fully andproperly maintained. Staff checked the log twice a day.

• The medicines and drugs cupboard keys were kept inthe office, which staff told us was always either locked ormanned. It is good practice for keys to be held by aspecific named member of staff. We discussed this withthe service manager who said he would address this.

• Staff worked with clients to ensure they gained as muchindependence with their medicines as possible, and atthe time of our inspection, clients administered their

own medicines with staff support. An assessment wasundertaken to ensure clients were able to safelymanage their medicines, with staff support beingreduced over time to promote as much independenceas possible.

• Naloxone was available and easily accessible if it wasneeded. This is good practice as it means staff can actquickly in case of a client overdosing. All staff weretrained in the use of Naloxone.

• All staff were trained to administer medicines as part oftheir induction.

Track record on safety

• The service has had no critical incidents in the last year.

Reporting incidents and learning from when thingsgo wrong

• Clear incident and critical incident policies were inplace. Incidents were reported via the electronic systemwhich flagged them to the service manager and thechief executive. The system tracked the incident toensure necessary actions were taken in a timely manner.

• Staff liaised with partner agencies where appropriate,for joint working or information sharing, such as CGLand commissioners.

• Staff were able to give us examples of what incidents toreport and how to report them.

• Records showed that incidents were appropriatelymanaged and recorded. If any lessons could be learnedfrom incidents these were shared with staff at teammeetings and handovers.

• The outcomes of incidents were shared, if appropriate,with clients in house meetings.

• An example of learning following an incident is thereview and improvement of policy and practice aroundmonitoring online prescriptions, which meant clientscould obtain additional medicines above their GP’sprescription.

• The service had an appropriate duty of candour policy.This meant they were open and transparent, and gavepeople using the service and families a full explanationif something goes wrong.

Are services safe?By safe, we mean that people are protected from abuse* and avoidable harm

Good –––

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Our findingsAssessment of needs and planning of care

• During our inspection we reviewed eight care records.All were fully and appropriately completed, detailed andpersonalised, with clear evidence of client involvement.All reviews were completed in a timely manner, eitherquarterly or more often if needed.

• Clients were always offered a copy of their support planand assessments.

• Staff undertook a two-stage assessment, usingrecognised tools, looking at multiple factors, such asoffending history, motivation and responsibility,physical health, mental health, substance misusehistory, housing and expectations.

• Staff worked with clients to develop recovery-orientedsupport plans that met the needs identified duringassessment, with clearly identified goals.

• The support plans identified the person's key worker/care co-ordinator.

Best practice in treatment and care

• The service did not follow any specific recovery model,but supported range of options dependent on whatsuited an individual’s needs.

• The organisation was recovery focused and had apathway for people to move through, support increasingor decreasing as people needed. With its communityfocus, the service had links with a wide range of otherservices, including CGL which was a local substancemisuse support service, Emerging Futures, which offersservices such as training, counselling and support forpeople trying to get back into the workplace, and socialsupport via the Turning Tide Community Hubs.

• The service used recognised assessment tools such asCESI, a psychological and social profiling tool from theTexas Institute of Addictive Behaviour, and the HostelOpiate Overdose Risk Assessment Tool (HOORAT), theClinical Institute Withdrawal Assessment for Alcohol(CIWA) was used. Where appropriate, a Severity ofAlcohol Dependence Questionnaire (SADQ) wasundertaken. This is a short, self-administered

questionnaire designed by the World HealthOrganisation to measure severity of dependence onalcohol. Assessments were undertaken in line with NICEbest practice quality standards.

• The service used recognised outcome measuring toolssuch as the star tool. This is an evidence-based tool formeasuring and supporting change when working withpeople, based on values of empowerment,collaboration and integration.

• All staff and most clients were trained in use ofNaloxone. Clients at risk of opiate overdose carried theirown Naloxone, and further supplies were easilyaccessible in the staff office.

• The service had a mixed complex needs team and adual diagnosis worker to provide specialist support toclients with the most complex needs.

• Relevant and current evidence based best practiceguidance, for example NICE guidance around relating tothe management of medicines.

• The service referred clients to the GP or CGL for bloodborne virus testing, in line with NICE best practicequality standards.

• There were leaflets and posters visible in the mainhallway area of the service, with information aboutcommunity health, methadone, employmentopportunities, careers services, relapse prevention,volunteering and counselling, among others.

• On admission, clients signed an agreement outliningsome basic ‘house rules’, pertaining to respect andsafety. These were not always adhered to, and someclients felt that the service did not always actconsistently in response to these instances. This meantsome clients felt that others got more ‘chances’ thanthem. We discussed this with the registered and servicemanagers who told us this was difficult to managebecause of confidentiality issues in discussingindividuals. However, they said they would considermore generic discussions they could have with clients totry to explain why this may appear to be the case toensure all concerns are addressed

Skilled staff to deliver care

Are services effective?By effective, we mean that people’s care, treatment and support achieves goodoutcomes, promotes a good quality of life and is based on the best availableevidence.

Good –––

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• The organisation employed a training coordinator whowas responsible for ensuring all mandatory training wascompleted and refreshed as necessary. They alsosourced, arranged and evaluated specialist training.

• All staff were given a comprehensive induction, withmandatory sessions including safeguarding and mentalcapacity, health and safety, fire safety, boundaries,confidentiality and medication training.

• Specialist training provided recently included traumaand suicide prevention.

• Managers identified the learning needs of staff throughsupervision, appraisals and client feedback, andprovided them with opportunities to develop their skillsand knowledge.

• All staff received regular supervision and annualappraisal from appropriate professionals. This includedreview of their development plan which was personal toeach staff member.

• Poor staff performance was addressed promptly andeffectively. The organisation operated a no blameculture and would support people as much as possiblebefore resorting to formal processes. Support may haveincluded additional training or a transfer to a role moresuited to their skills. A human resources team supportedmanagers in staff performance issues.

• The organisation had around 200 volunteers who weretrained and supported for their individual roles.Volunteers might be ex-clients, friends or relatives ofclients or people just interested and wanting to help.The level of support volunteers offered ranged from ahigh level such as several days a week, down to a fewhours as and when needed for events.

• Staff attended monthly reflective practice sessionsfacilitated by an external counsellor.

Multi-disciplinary and inter-agency team work

• At weekly meetings, the multi-disciplinary team wouldlook at referrals and make joint decisions about whichpotential clients may be the most appropriate for aninitial assessment.

• Where appropriate, care coordinators were clearlyidentified, and effective joint working protocols were inplace to ensure there was regular communication andproper information sharing.

• The service had effective protocols in place for theshared care of people who used their services. Theservice had very strong relationships with a wide rangeof other agencies and professionals. These includedcommissioners, the probation service, GP surgery, thelocal authority, CGL, Emerging Futures, the police, localpharmacies, the ambulance service and local domesticviolence services. The registered manager was skilled atbuilding relationships and ensuring the communityethos of the organisation is practiced fully andeffectively.

Good practice in applying the Mental Capacity Act

• The service had an appropriate mental capacity policywhich staff were aware of.

• Staff ensured that clients consented to care andtreatment and were involved in decisions, that this wasassessed, recorded and reviewed in a timely manner.

• Staff received training in the Mental Capacity Act as partof their safeguarding training. However, individualmembers of staff’s knowledge of the legislation andtheir duties around mental capacity was variable.

Are services effective?By effective, we mean that people’s care, treatment and support achieves goodoutcomes, promotes a good quality of life and is based on the best availableevidence.

Good –––

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Our findingsKindness, dignity, respect and support

• There was a strong, visible person-centred culture.During our inspection we saw staff interacting withclients respectfully, kindly and appropriately. Weobserved staff providing responsive, practical andemotional support.

• Clients we spoke with told us staff were visible andsupportive, and that staff made them feel that theymattered. Clients had enough one to one time with theirdesignated keyworker, and could request more if theyneeded to. Staff prioritised such requests, even at shortnotice. Private spaces were available for confidentialdiscussions.

• Staff recognised the totality of people’s needs andstrove to find innovative ways to support them. Servicemanagers referred regularly to providing a ‘wraparoundservice’, to ensure all needs were met. Staff recognisedthe importance of building and maintaining supportnetworks in the community and they were very strong insupporting people to do this.

• Staff supported clients to understand and manage theirrecovery. Staff signposted clients to other services whenappropriate and supported them to access thoseservices.

• On arrival at the service, new clients would be assigneda buddy who would help orient them, show themaround and help with any advice or questions in theinitial weeks.

• Clients told us they liked the feeling of inclusion, oneexample being the family feeling of Christmas-time, withgifts being exchanged and a full Christmas dinnerprepared and eaten together.

• Clear confidentiality policies were in place that wereunderstood and adhered to by staff. Staff maintainedthe confidentiality of information about clients.

• Staff said they could raise concerns without fear of theconsequences, although they had never needed to doso.

• The service had a client charter that was developed byclients for clients, and aligned with that they haddeveloped a staff charter, both these documents set outexpectations around behaviour and how everyonewithin the service committed to treating each other.

• The service recognised that relapses are part of arecovery journey, and treated clients with support,dignity and respect during a relapse.

The involvement of people in the care that theyreceive

• All risk and needs assessments, and resulting treatmentand support plans were conducted and completed withthe full input of the individual. Clients told us they feltvery involved and in control of the treatment process.

• The partnership and co-production team (PACT), was aconsultation group made up of client representativesfrom across Turning Tides Homelessness services. PACTconducted focus groups and client surveys, which wereused to inform how the service was run and developed.PACT had input into any reviews of organisational policyand procedures, and were consulted on about servicebudgets. They also held monthly meetings with clients,staff and managers, including senior managers and thechief executive, to build and develop co productionwithin the organisation. PACT had developed bespoketraining which they delivered to senior managers andthe trustees. The service actively encouraged clients toget involved with PACT.

• The service sought client feedback in a variety of ways.There were comments cards in the hallway and anannual written survey was conducted, in addition to theface to face PACT survey. Feedback was soughtregarding keyworkers after each session, and this wasused to monitor staff performance.

• Monthly house meetings were held, and were bothchaired and minuted by clients. All issues relating to therunning of the house were discussed and actionsaddressed as a result.

• Clients were involved in all recruitment for the service.They helped to create interview questions, sat on theinterview panel and had a vote on decisions equal tothat of other panel members. Clients designed anddelivered training to new staff.

Are services caring?By caring, we mean that staff involve and treat people with compassion,kindness, dignity and respect.

Outstanding –

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• Carers and families could feed back using thecomments cards or by talking to staff.

Are services caring?By caring, we mean that staff involve and treat people with compassion,kindness, dignity and respect.

Outstanding –

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Our findingsAccess and discharge

• Turning Tides Homelessness recovery service had aclearly documented admission criteria. People neededto be homeless adults with substance misuses issuesand be genuinely motivated to address those issues andimprove their lives.

• Most referrals were made via the Turning TidesHomelessness day centre; however, some were alsomade by the local authority or the probation service.

• A multi-disciplinary team would look at referrals andmake joint decisions about who was most appropriatefor an initial assessment. Although the service had awaiting list, clients were never left on the streets, as aplacement elsewhere within the organisation or with apartner organisation would be identified for people.

• Turning Tides Homelessness did not subscribe to anyparticular treatment model and would support anytreatment plan that suited an individual’s needs.

• Clients were supported through discharge, and theirrecovery included preparation for moving on. Manyclients went onto the organisation’s community homes,and all clients received community support for as longas they needed it.

The facilities promote recovery, comfort, dignityand confidentiality

• Each client had their own bedroom with a staff call bellfor emergencies, and there were several sharedbathrooms in the service. Each bedroom wascomfortably furnished, and clients could personalise asthey wished. Some clients had fridges and microwavesin their rooms.

• On admission, each client was given clothing andtoiletries.

• The service had a shared lounge where clients couldsocialise or have movie nights, and there were spacesfor arts and crafts, a gym, a dartboard and a pool table.There was a stocked kitchen that clients could access 24hours a day.

• There was a bookable family room where clients couldhave visitors, including their children. This was subjectto guidelines agreed in advance, and clients weresupported by a family social worker around children’svisits.

• There was a covered area with heaters for smoking inthe garden.

• There were private rooms where people could speakconfidentially with staff or their keyworker.

Meeting the needs of all people who use theservice

• The service had an equality and diversity policy, whichwas part of the staff induction, and no referral wasturned down because of any diversity related factor. Theservice operated in a non-judgemental manner.

• Managers and staff demonstrated an understanding ofthe potential issues facing vulnerable groups e.g.women, sex workers, people from a range of ethnicgroups, older people, people at risk of domesticviolence and people from the LGBTQ+ community.

• The hallways were wide enough for wheelchair usersand the service had lifts and ramps for people withmobility needs. Bedrooms on the ground floor weresuitable for people with mobility needs and wheelchairusers, and one bedroom is adapted with accessibleshower and facilities. If additional disability accessiblerooms were needed the service would make furtheradaptations.

• The residential service considered referrals frompregnant women, and the organisation’s day centre hada day designated for only female clients.

• Clients could keep their pets at the service, as clientshighlighted that being unable to have their dogs at theservice was a barrier to accessing residential recoveryservices.

• Staff supported clients to follow whatever faith theychose, and have also helped clients to find their faith ifthey needed that support.

• The service had supported transgender clients,including one person who underwent genderreassignment while in recovery at the service.

Are services responsive topeople’s needs?By responsive, we mean that services are organised so that they meet people’s needs.

Good –––

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• Staff could access interpreters and signers if needed,and the communications team could provideinformation in a range of languages, large print or inbraille. People with literacy needs would be supportedby their buddy, keyworker or someone from PACT.

• The service met people’s recovery needs in a way thatsuited them, supporting any approach clients felt wouldwork for them. The service also used a unique managedwithdrawal from alcohol program, which was tailored toan individual based on a range of factors, includingseverity of dependency, gender, weight etc. Apersonalised reduction plan was created, discussed andagreed with the client, which was then closelymonitored by the staff team issuing correct and agreedamounts of alcohol at intervals set out in the agreedwithdrawal from alcohol plan. The programme could beaccelerated or slowed down depending on the client’sreaction to the reduction, so each client would take adifferent duration to reach abstinence. The programmedid not involve any prescribed medicines for withdrawalsymptoms and was not medically monitored.

Listening to and learning from concerns andcomplaints

• A clear complaints policy and process was in place.Complaints were managed by an appropriate grade ofstaff member depending on the nature of thecomplaint.

• Clients were given information about how to make acomplaint as part of their assessment, and there wereinformation leaflets in the hallway.

• Someone from the PACT team would support clientsduring the complaints process if they wanted or neededit.

• Records showed that complaints were appropriatelymanaged and recorded. If any lessons could be learnedfrom complaints these were shared with staff at teammeetings and handovers.

• The outcomes of complaints were shared, ifappropriate, with clients in house meetings.

• Examples of changes made following complaints were;a canopy and outside heaters were installed in thesmoking area outside following complaints from clientsabout being cold, and a new kitchenette area wascreated with stainless steel shelves and work surfacesfollowing complaints that the kitchenette area in thedining room was becoming hard to clean.

• Managers reported on complaint activity to the chiefexecutive and the board of trustees in their quarterlyquality report.

Are services responsive topeople’s needs?By responsive, we mean that services are organised so that they meet people’s needs.

Good –––

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Our findingsLeadership

• Leaders had the skills, knowledge and experience toperform their roles. The registered manager had beenwith the organisation for 13 years and was instrumentalin setting up the service. The service manager, whomanaged the day to day running of the service,provided consistent leadership to service staff, whowere positive about his support.

• Last year all managers in the organisation underwent atraining programme delivered over six days. Servicemanagers told us this training was very effective.

• The organisation was in the process of developing atraining programme, and as part of that, all Turning TideHomelessness managers will meet at quarterlyworkshops where there will be relevant training andtime for action learning groups to form and work onshared challenges.

• Leaders were visible in the service, and approachablefor clients and supportive to staff. Senior staff were veryvisible throughout the organisation and servicemanagers told us the chief executive was verysupportive and visited the service regularly.

• The board of trustees, to whom the leadership teamreported, was comprised of people with a diverse rangeof skills and experience. The trustees were also involvedin the running of the service and accessible to staff andclients for feedback and discussions.

• A meetings structure was in place, with monthly seniorleadership meetings, managers meetings and servicestaff meetings ensuring that information, developmentsand learning was cascaded through the organisationappropriately.

• Annual staff away days focussed on key issues andensured that staff at all levels had the opportunity toinput into the development of the organisation.

• The organisation had a clear definition of recovery andthis was shared and understood by staff.

Vision and values

• Staff knew and understood the vision and values of theteam and organisation and what their role was inachieving that. This was reflected in the way supportwas delivered.

• Staff had the opportunity to contribute to discussionsabout the strategy for their service, especially where theservice was changing, and targets reflected these. Teammeetings and staff away days focused on theorganisation’s values.

Culture

• Staff told us they were happy in their roles, and feltrespected, valued and supported.

• The culture of the organisation and the service wasopen, and staff felt confident to raise concerns if theyneeded to.

• Staff appraisals included conversations about careerdevelopment and how it could be supported.

• Staff had access to support for their own physical andemotional health needs through an occupational healthand counselling services. Contact details for theseservices were on the back of staff identification badgesand were therefore always accessible.

Good governance

• The service used a range of key performance indicatorsto monitor the service and measure outcomes. Some ofthese were set by the organisation and others by thecommissioning authority.

• Quarterly contract review meetings were held withcommissioners.

• There was a clear structure for senior management,management and team meetings, ensuring thatessential information, such as learning from incidentsand complaints, was cascaded and used to improveservice provision.

• Service managers submitted quarterly qualitymonitoring reports to senior managers and the trustees.This report included safeguarding information,incidents and audit outcomes.

Management of risk, issues and performance

Are services well-led?By well-led, we mean that the leadership, management and governance of theorganisation assure the delivery of high-quality person-centred care, supportslearning and innovation, and promotes an open and fair culture.

Good –––

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• Staff maintained a risk register which was regularlyreviewed. Items on the risk register were RAG rated forprioritisation purposes, and each risk had its’ ownaction plan.

• The service budget included a contingency for repairs orthe need for unexpected upgrades. An example of thiswas the fitting of new fire doors in response to anational incident.

Information management

• Staff had access to enough equipment and informationtechnology needed to do their work. All informationneeded to deliver care was stored electronically andwas available to staff who had their own passwordprotected access to systems.

• Information governance systems included measures toensure the confidentiality of patient records ismaintained.

• Staff shared information with external bodies such ascommissioners and other professionals as appropriate,however the CQC has not received any statutorynotifications in the last year. We were concerned thatthe provider may not have been routinely sendingnotifications following reportable incidents as, given thenature of the service, it is likely reportable incidents mayhave occurred. This was discussed with the registeredand service managers during the inspection, and theyagreed to undertake a review of their process to ensureCQC is notified appropriately of any incidents.

• Service managers had developed effective joint-workingarrangements with other professionals andstakeholders.

Leadership, morale and staff engagement

• Staff, clients and carers had access to up-to-dateinformation about the work of the provider throughregular meetings, PACT and bi-monthly newsletters.

• Clients and their representatives or carers had a varietyof opportunities to give feedback on the service.

• Clients and staff could meet with members of theprovider’s senior leadership team to give feedback. Thechief executive often visited the service and got involvedin events, such as barbecues.

• The organisation engaged with clients formally throughPACT, who had significant input into all aspects of theorganisation, including policies and budgets.

• Service managers engaged well with an extensive rageof external stakeholders – such as commissioners, theprobation service, GP surgery, the local authority, CGL,Emerging Futures, the police, local pharmacies, theambulance service and local domestic violenceservices.

Commitment to quality improvement andinnovation

• The service used an innovative managed withdrawalfrom alcohol programme, which was designed by theregistered manager in partnership with colleagues fromother disciplines. This was the only programme of itskind in the country and the service managers advised usthat this programme had been independently evaluatedby a medically qualified detoxification specialist, andapproved by Public Health England.

• The registered manager was part of the West SussexReducing Drug Deaths Group and of the West SussexDrug and Alcohol tier 4 governance group. This was amulti-disciplinary group, including the police,commissioners, the coroner, ambulance service andlocal pharmacies, which met bi-monthly and wouldundertake thematic reviews of significant deaths, to tryto reduce the number of drug and alcohol relateddeaths.

• Turning Tides Homelessness was part of a SystemsLeadership Programme that encouraged organisationsand key decision makers from all parts of the system tocome together to resolve complicated issues. A currentpriority was preventing discharge of people whose onlyalternative is the street.

• The organisation monitored and measured long termoutcomes following treatment where clients were nowliving independently in the community.

Are services well-led?By well-led, we mean that the leadership, management and governance of theorganisation assure the delivery of high-quality person-centred care, supportslearning and innovation, and promotes an open and fair culture.

Good –––

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