Quality Standards fr Cmmunity Substance Misuse Services Intrductin Implementatin Guide - 2016 The Implementatin Guide is written t help cmmunity substance misuse services t gather the evidence they need in a structured way in rder t meet the quality standards. Thrughut the guide there will be crss references t the quality standards which highlight particular plicies and prcedures necessary t ensure gd practice. The dcuments shuld therefre be used in parallel. The apprach taken will be allied t the CQC methdlgy s that services which are registered can prepare well fr their inspectins. Fr services that are nt registered this is still a useful framewrk because it ensures that prviders have examined their service in an rganised and fcussed way. It is imprtant t state that sme cmmunity services are registered with CQC if they fulfil the criteria f having in the multi-disciplinary team peple wh are medical practitiners including nurses r scial wrkers. If s then they will be registered t prvide Treatment fr disease, disrder r injury. Usually this means that the service is a prescribing service. If these prfessinals are nt part f the team, r if they hld a CQC registratin elsewhere fr example at a GP practice, then registratin is nt required. Whilst the Quality Standards are gruped accrding t practice issues, this implementatin guide grups the issues directly mapping the CQC Key Lines f Enquiry as utilised by CQC when they cmpile their reprts. S if all these pints are evidenced then a service can be assured that they have been thrugh in cvering all the areas which a CQC Inspectr will assess as part f their inspectin. When gathering evidence it is imprtant t understand that this is nt just dcumentary evidence, but it can als be gained by talking with staff, peple wh use services, and by bservatin f practice. Fr example it is all very well having a plicy n dignity and privacy f treatment but if service users say that they d nt feel treated with dignity, r if facilities actually allw n privacy, then it is nt achieved. Anther example is service user invlvement in care planning. There may well be a sectin fr service user cmments in the plan, but if it is nt cmpleted, r if service users say that they have never seen it, r they d nt have a cpy, then it is clearly nt happening in practice. This implementatin guide will seek t be practical abut exactly what evidence is required t demnstrate that quality standards are being met. It may be helpful fr managers f services t devise a rutine whereby they ensure that ver a year they update each f the five questins. A practical apprach wuld be t cver the questins ne at a time n a tw mnthly cycle, with a summary being prduced n the sixth ccasin fr example. 1
Other ways f ensuring that services keep t standards culd be the setting up f a gvernance grup which culd review crucial matters such as safeguarding, serius incidents, cmplaints and changes t plicies as well as receiving quality assurance reprts. Having a set frequency with which t review plicies is helpful t ensure that nne are ut f date r irrelevant t the service being prvided. This grup culd have a wide representatin, including service users, t ensure that all aspects f the service are verseen and any changes t the service are understd and implemented. The existence f a service user frum is als a useful way f btaining feedback abut hw the service is being received. Enabling this frum t have a direct rute int the senir management is imprtant in ensuring that the service user remains at the centre f the service prvisin. The verall aim will be t make sure that service users will be prvided with a service that is fcussed n their needs and their persnal recvery jurney. 2
1. Is the service safe? This is the mst crucial element f the peratin f a cmmunity service. The key issues are the envirnment, the management f risk, the track recrd n safety, lessns learned and imprvements made, safe staffing, safeguarding, and emergency planning. S what can be cnsidered under each f these headings? A. Safe and clean envirnment Standard 9 Service Envirnment The cleanliness and welcming feel f the premises frm which a service perates influence the experience f smene cming t use the service. Is the service easy t find? Is the presentatin f the service institutinal r persnal? Gd examples f welcming services can include the availability f refreshments, a welcme team which can ften be peer mentrs r vlunteers, and clear signage. The actual premises need t be kept safe, clean and secure. In rder t d this the fllwing may be useful: Welcming envirnment Open and accessible receptin facilities. Staff and vlunteers wh are designated the task f welcming peple. Cleaning schedules & infectin cntrl arrangements. It is imprtant that there is an infectin cntrl lead persn wh implements Department f Health guidance n infectin cntrl. The lead persn ensures that there is a regular audit f infectin cntrl. Usual infectin cntrl arrangements including hand washing signs. Staff can be trained in infectin cntrl. The treatment rm needs particular attentin if BBV and drug and alchl testing ccurs. In additin, the treatment rm will ideally include rescue medicatin, resuscitatin equipment and training and a defibrillatr (AED). Remval f clinical waste is als imprtant, usually thrugh a cntractr. An envirnmental risk register This is useful because it clarifies any risks in the premises. This shuld include a risk management plan. Particularly lk ut fr ligature pints and access fr peple with disabilities. Als address the issue f the level f staff bservatin f waiting areas and clinical rms. Fire evacuatin and safety prcedures and equipment Ensure that yu have fire evacuatins planned and recrded. Ensure that there is a Fire Safety risk assessment. Lcal fire and rescue services smetimes prvide this, r there are many independent cmpanies wh ffer this service. Maintenance f premises examples can include: 3
Servicing recrds fr any heating equipment. PAT testing f any electrical equipment. Leginella testing. B. Risk Assessment Standard 3 Initial Assessment The way in which risks t peple wh use services are assessed and managed is very imprtant t ensure that they are safe. Prir t admissin t the service Fcus n medical issues such as the risk f seizure, delirium tremens, and ther symptms assciated with piate r alchl withdrawal. (Specifically crss reference NICE Guidance CG100 & CG52.) A cmprehensive health assessment by a qualified practitiner in rder t ensure that health risks are understd and managed well. Substance misuse specific risks are identified e.g. risk f verdse, ply drug use, injecting needles, BBV, etc. Where there are identified risks there is an accmpanying risk management plan. Once peple are in treatment Standard 11 Health & Wellbeing Risks t changing health care needs are identified, especially anything related t drug and alchl harm. Prcedures fr mnitring health are practiced e.g. check-ups with a nurse, weight mnitring, bld tests etc. There are cmprehensive risk assessments in place which cver areas mentined in the NTA Care Planning Guide e.g. drug and alchl use, physical and psychlgical health, criminal invlvement and ffending, scial functining including family histry. (NTA 2006) Plicy and prcedures t manage the risks assciated with restraint and challenging behaviur. Plicy and prcedure t manage the risks f suicide e.g. ligature pints. Prescribing practices Standard 1 Safe prescribing Ensure that the prescribing dctr, r nn-medical prescribing nurse, is wrking n the basis f a cmprehensive risk assessment. Ensure that NICE prescribing guidelines are being fllwed. Ensure that prescribing is n the basis f a face t face assessment by the practitiner. C. Medicines management Standard 1 Safe prescribing Once medicatin is prescribed the way in which medicatin is managed in a service is imprtant fr keeping peple safe. Whilst many service users will self-administer, r receive their medicatin at a supervising pharmacy, it is imprtant that there are clear guidelines in place. Self-administratin f medicatin An verview f hw each service user is managing their medicatin administratin. 4
Cntrlled drugs Cntrlled drugs arrangements cmpliance with Misuse f Drugs Act 1971. Lcked cabinet. Medicatin kept at the service. Medicine management supprt f pharmacy, audit f errrs, administratin, staff training & cmpetency assessment, awareness f duble scripting, cmpliance with Medicine Act 1968. Management f needle exchange and BBV Standard 2 Needle exchange prvisin Have a range f syringes, needles and ther equipment available t meet the needs f users f a range f substances, including thse wh use Image and Perfrmance Enhancing Drugs (IPEDs). Prvide health advice and infrmatin. Have written plicies and prcedures that utline the delivery f needle exchange prvisin in bth cmmunity service site based and pharmacy-based needle exchange, including access t Hepatitis B vaccinatin and Hepatitis C & HIV testing. Have develped care pathways with a range f health services, including sexual health, hepatlgy and mental health. Review needle exchange prvisin at planned and regular intervals. D. Track recrd n safety & lessns learned Standard 7 Clinical Gvernance It is imprtant that a service keeps recrds t shw that safety is well managed. Managers need t have an verview f any incidents r events which may cmprmise the safety f service users. Examples f gd ways t d this are: A system fr recrding recent adverse events and serius incidents i.e. Integrated Gvernance Regular multi-disciplinary reviews f incidents, accidents, adverse events, safeguarding, cmplaints, etc. Staff wh knw reprting mechanisms. Feedback n lessns learned frm incidents t staff including a debrief. Tracking f changes t prcedures which result. Recrd f wh is infrmed e.g. line management structure. Service users say that they feel safe. Awareness f Duty f Candur when things g wrng r mistakes are made. Awareness f whistleblwing plicy and prcedure. E. Safe staffing Standard 14 Human Resurce Management T ensure the safety f service users it is imprtant that there are sufficient staff available t deliver the treatment and supprt which the service aims t prvide. 5
T demnstrate this the fllwing will be helpful: Staff team A list f the prfessinally qualified staff team with particular reference t the invlvement f clinical staff wh versee detxificatin. A list f recvery wrkers & supprt staff. A list f vlunteers wh undertake specific tasks within the service e.g. peer mentrs, recvery champins. Staff deplyment Detail abut hw staff requirement has been estimated e.g. number f key wrk sessins, grup wrk sessins, prescribing clinics, ther activities. Management f sickness/leave, als unexpected absences, use f agency r bank staff. Safe staff recruitment Standard 15 Recruiting staff and vlunteers Safe recruitment prcesses must be in place. Includes DBS checks prir t starting wrk, a risk assessment f any ffending r drug taking invlvement, tw references, ID check t ensure that peple can wrk in the UK, explratin f any gaps in CV, an applicatin frm and a recrd f the interview. F. Safeguarding It is imprtant that services understand the purpse f safeguarding prcedures as these can ensure that vulnerable peple are prtected frm abuse and kept safe. Smetimes infrmatin abut pssible abuse t children cmes t light and it is imprtant that this t is reprted t lcal children s safeguarding teams as this may be vital infrmatin which helps piece tgether the situatin f children wh may be at risk. In rder t d this the fllwing is suggested: There is a Safeguarding plicy & prcedure including anti-discriminatin. The safeguarding plicy includes children and adults. There is an accessible pster and written prcedure which clearly identifies the cntact pint fr the lcal safeguarding team fr adults and children. Staff are trained in awareness f safeguarding issues and managers are trained t investigate safeguarding cncerns, cmmnly referred t as level 4. Recrds are kept f safeguarding incidents & alerts. G. Emergency r business cntinuity plans A service is safe if it can demnstrate that it can manage cntingencies. Examples are: Unexpected lack f staff, r lss f use f building. A plan needs t be frmally in place. Out f hurs management cver if necessary. 6
2. Is the service effective? This means des the service wrk well? T shw this it is imprtant that specific building blcks are in place. These include cmprehensive assessments and rbust care plans which truly reflect the gals that service users are wrking twards. These assessments include the initial assessment phase as well as the cmprehensive assessment and care plans develped as a result. Standards 3 and 4 f the Quality Standards Framewrk utlines the essential elements well. Other key building blcks include a skilled and cmmitted wrkfrce which frms a chesive multi-disciplinary team. When it is wrking well this ensures that a range f perspectives are in place meaning that the care and treatment delivered can meaningfully be described as hlistic. Finally there is an increasing emphasis n ensuring that service users are knwingly cnsenting t their care and treatment. Where they are unable t d s, the service needs t be aware f the implicatins f the Mental Capacity Act. If the service is registered by CQC it is imprtant t understand that CQC has a statutry duty t versee the implementatin f the Mental Capacity Act. A. Assessment f care Standard 3 Initial Assessment It is imprtant that a service receives gd quality assessment infrmatin frm a care manager r ther referral rutes prir t admissin. This assessment infrmatin shuld include: Prfessinals invlved, physical and mental health issues, medicatin, histry f substance misuse, legal issues, scial & cultural issues include family histry & children, financial situatin & full risk screening. Als a physical health assessment by a suitably qualified dctr, including physical examinatin is vital s that the medical cnditin f the persn cming fr treatment is knwn and can be mnitred accurately thrughut their treatment jurney t ensure that symptms are understd and can be treated apprpriately if they ccur. B. Plan f Care Standard 4 Care Planning Care plans are develped as a result f cmprehensive assessments. They shuld be based entirely n the needs f service users. S key features f a gd care plan are that they: Reflect individual needs, risk and preferences. Invlve the service user in their preparatin. Offer the service user a cpy s that they take wnership f the prcess. Build n peple s strengths i.e. develp Recvery Capital. Include infrmatin abut nutritinal management. This is particularly imprtant where peple may have been neglecting themselves and becme under- 7
nurished. Others may have allergies which need t be taken int accunt and can seriusly affect peple s health. Unexpected discharge management, including harm minimisatin advice. Are regularly reviewed with the service user t ensure that gals are being met r targets reached. Als t ensure that the service is cnsenting t the plan and is actively wrking twards the agreed gals. C. Best Practice in treatment & care Standard 5 Psychscial interventins It is vitally imprtant that treatment delivered is evidence based and uses NICE guidance especially if detxificatin and withdrawal is invlved. If a service is CQC registered this will always be used as the measuring tl fr practice. Sme specific NICE Guidance is: GG 115 Alchl use disrders: diagnsis, assessment and management f harmful drinking and alchl dependence NICE 2011. CG100 Alchl use disrder: diagnsis and management f physical cmplicatins NICE 2010. CG 52 Drug misuse in ver 16s piid detxificatin NICE 2007 due t be revised in the autumn 2016. CG51 Drug misuse in ver 16s psychscial interventins NICE 2007. Als: Drug misuse and dependence UK guidelines n clinical management DH 2007 (T be reviewed 2016) Medicatins in Recvery: Re-rientating drug dependence treatment J. Strang NTA 2012 knwn as The Strang Reprt. Where psychlgical therapies are used then it is imprtant that there is an independent, verified evidence base fr that treatment. This als applies t any cmplementary therapies that may be ffered as part f the service. D. Skilled staff t deliver care and treatment Standard 17 Managing staff and vlunteer develpment Standard 18 Staff and vlunteer inductin This means that staff need t be cmpetent t deliver the care and treatment ffered by the service. Essentially this means qualificatins, training and relevant experience. A practical way f demnstrating this is t have a training matrix available s that mandatry and specialist training can be tracked acrss the staff team t ensure that all staff have the right raining fr the rle they are being asked t undertake. It is imprtant that staff are prperly supervised and have an annual appraisal in rder t mnitr their develpment and practice and t set gals fr the future. 8
A recent develpment has been the intrductin f the Care Certificate in place f the Cmmn Inductin Standards. Sme features f staff training are: Staff knwledge f the treatment n ffer especially detx and its side effects, als the philsphy f the treatment prgramme. Ability t recgnise deterirating health cnditins. Inductin checklists & Care Certificate cmpliance. Mandatry training n a training matrix with a training plan. Specialist training and cntinuing prfessinal develpment (CPD). Prfessinal Registratin f medical staff (RGCP part 1 & 2), drug and alchl wrkers with FDAP and cunsellrs with BACP. Supervisin which must be regular, planned and recrded. This can be individual and/r grup supervisin which can be external where relevant. Appraisal must be annual, preceded by a prbatinary timeline. E. Multidisciplinary and interagency team wrk Standard 10 Jint wrking It is vital that treatment is delivered frm a multidisciplinary team framewrk s that the needs f service users are cmprehensively assessed and plans are well crdinated. In rder t achieve this the fllwing will be helpful: Regular meetings with stakehlders. Cmmunicatin acrss the team, fr example clinical meetings r telephne cntact t especially highlight medical and ther prfessinal input. Invlvement f Cmmunity Mental Health Team (CMHT). Handver meetings fr cmmunicatin f service user issues bearing in mind cnfidentiality issues. Staff meetings. Transitin between services well managed e.g. cmmunity services t hspital r residential settings. Links with lcal recvery cmmunity grups and mutual aid. Adherence t the Mental Health Act If service users have mental health issues then it is imprtant that they receive the right psychiatric assessment and interventin. S gd referral rutes need t be established if the need arises. Where mental health issues are psychiatrically diagnsed and severe peple may be a risk t themselves r thers s there needs t be an awareness f the mental health services which will be relevant t this situatin. 9
Gd practice in applying the Mental Capacity Act 2005 It is imprtant that staff have basic understanding f the Mental Capacity Act 2005 thrugh training s that they can be aware f the need fr peple t have capacity in rder t engage in treatment. S staff need t knw that they must check if smene has capacity t cnsent t treatment. Clinical and medicatin recrds must shw that staff seek cnsent t treatment as well as cnsent t share infrmatin. If there are any restrictins r bundaries which are necessary within the treatment plan then are explained, agreed, reviewed and frm part f nging treatment. 10
3. Is the service caring? It is smetimes difficult t quantify hw t measure whether r nt a service is caring as it largely fcusses n the values that staff demnstrate in their wrk as well the values f the rganisatin. As an rganisatin, a service may have service user invlvement strategies such as peer mentrs r service user invlvement frums. Listening t service users demnstrates an inclusive apprach t service delivery. The questin f accessibility f the service is imprtant in terms f the premises, the lcatin and the services ability t be available t the range f vulnerable grups in sciety. Sme f the ways in which sme evidence is btained are thrugh bservatin f interactins and thrugh asking service users directly r thrugh surveys. Areas t cver are as fllws: A. Kindness, dignity, respect and supprt Managers can directly ask service users if their staff are kind and supprtive, emtinally and practically. Psitive interactins between staff and service users are bserved as being warm, respectful, kind, supprtive, cnscientius, empathetic, sensitive, encuraging and prfessinal. Service users say t managers, r thrugh surveys that they feel respected & nt judged. Existence f a structure t prmte dignity e.g. dignity champins. Handver meetings are respectful and cnfidential. B. The invlvement f peple in the care they receive Standard 12 Develping service user invlvement This can be n an individual level as well as rganisatin level and includes elements such as: Service user invlvement in planning f care & treatment evidenced thrugh signatures f service users n care plans, and use f the service users wn wrds. The allcatin f peer supprt r a buddy. Rm fr visitrs including children at suitable times. Feedback thrugh surveys and questinnaires. Structure fr listening t service users e.g. huse meetings. C. Invlvement f carers r families in treatment Standard 13 Develping carer invlvement Families and carers invlved if service user gives cnsent. Advcacy where relevant e.g. vulnerable grups r n family supprt. 11
D. Meeting the needs f all peple wh use the service Ensuring diversity is respected fr example: Plicies and prcedures cmpliant with Equalities Act. Persnal, cultural, scial & religius needs highlighted in care plans relevance t substance misuse. Availability f interpreters. Access t spiritual supprt. Vulnerable grups and cmplex needs e.g. dual diagnsis, multiple drug use, hmelessness, pregnant wmen, criminal justice element, LGBT, yung peple. Reasnable adjustments fr disability tur f premises, access t premises & treatment prgramme. 12
4. Is the service respnsive? This fcusses n whether the service can meet the needs f service users in a timely and prfessinal way. It als asks if cncerns and cmplaints are listened t and frm part f a services ability t reflect n its wn practice. Imprtant elements are as fllws: A. Access and discharge Standard 10 jint wrking It is imprtant that cmmunity services have efficient access and discharge arrangements t ensure that service users receive treatment at the pint when they need and it can be efficiently delivered. Similarly when service users leave treatment they need t be reassured that there is nging supprt in the cmmunity which benefits them. When they are being referred service users need t have accurate infrmatin abut the service s that they can cnsciusly chse where t g fr their treatment. In rder t d this the fllwing is useful: Gd infrmatin is available in an accessible frm which describes the treatment n ffer at the service. Standard 8 Service Infrmatin Waiting times are kept t a minimum. Early discharge arrangements if terms f treatment are breached are made explicit. After care plans invlve stakehlders as relevant e.g. care managers, husing prviders, educatin, members f recvery cmmunity & mutual aid. Outcmes fr service users discharged are mnitred. B. The facilities prmte recvery, cmfrt, dignity and cnfidentiality Privacy is available fr cnsultatins and key wrk. In grup wrk settings, there are bundaries which preserve peple s privacy and cnfidentiality. Envirnment is suitable fr the use t which it is put. Additinal activities are relevant t the recvery jurney and are planned. C. Listening t and learning frm cncerns and cmplaints Respnse t feedback individual and grup e.g. service user frums. Service user awareness f cmplaints prcedure displayed and individually available? Demnstrate learning frm cncerns and cmplaints. Manager keeps cmplaints lg t demnstrate respnsiveness. 13
5. Is the service well led? It is abslutely crucial that a service is well managed and that leadership is visible. There are many elements t this and a service needs t demnstrate them all in rder t be reassured that it is being well led. Sme key elements are: A. Visin and Values f the rganisatin There is a statement f the values f the rganisatin, including an understanding f what recvery means. The rganisatins values are cmmunicated t teams. Staff understand the visin and values well. Chief Officers f the rganisatin regularly visit and mnitr and evaluate. B. Gd gvernance Standard 6 Organisatinal Gvernance This tpic is abut the rganisatinal structure, the lines f accuntability within the structure and the way in which risks within the rganisatin are assessed. A useful way f verseeing this is t establish a Gvernance meeting which may be referred t as Clinical Gvernance if there are a significant amunt f medical services invlved r Quality Gvernance if ther mdalities predminate. Overall there needs t be a Management Bdy which takes respnsibility fr the running f the service, usually thrugh the appintment f a manager, r if it is a larger rganisatin there will be a line management system in place. Sme key elements f gvernance are: A strategic business plan with bjectives. A line management structure which has clearly defined accuntabilities. A service wide risk register exists, nrmally cnsidered at a Gvernance meeting. If there is medical practice e.g. prescribing, then clinical audits are carried ut and reprted thrugh a clinical gvernance structure. Examples f audits are medicatin administratin, medical reviews, care plans, risk assessments. Lessns learned are cmmunicated well t staff and influence the develpment f practice. Staff understd the implicatins f the audits. Senir staff review audits at Bard level, r equivalent. Incidents are investigated prmptly, lessns learned identified and practice based learning is implemented. 14
Systems ensure that mandatry training as well as rle specific training is prvided fr staff. Infrmatin is btained frm previus service users abut the quality f the service. Staff understand whistleblwing thrugh a well cmmunicated prcedure. C. Leadership, mrale and staff engagement An pen and transparent management style is healthy fr the develpment f trust within an rganisatin. Sme features which may help t develp this are: Senir managers are seen as supprtive. A psitive level f mrale in staff team. Opprtunities fr staff develpment. Transparency when staff reprted back t service users if anything had gne wrng (this is the Duty f Candur). Staff feel that they have pprtunities t suggest imprvements t the service. D. Cmmitment t quality imprvement and innvatin When lking t the future it is inevitable that the cntext f treatment fr drug and alchl misuse will change. There will als be theretical, legal and clinical develpments as well as wider scial and plitical changes. In additin service user s expectatins may vary ver time. It is therefre essential that services cntinually lk t develp practice and scan the hrizn in rder t remain up t date as well as innvative in the way the service wrks. Sme features may include: A well-develped quality assurance prcess which seeks cntinual imprvement. A system fr keeping up-t-date with legislative changes. An up-t-date verview f best practice in the field. Cmmitment t innvatin thrugh service develpment initiatives. Participatin in research, practice placements r ther develpments. Links with external agencies where there are new initiatives taking place. 15