Archived: Brook Dudley

Updated 8 June 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

Brook Dudley is a charity providing free, confidential sexual health and well-being services for young people under the age of 25.Between January 2016 and October 2016 Brook Dudley saw 701 young people under 18 years old and 1565 young people aged between 18 and 25 years. Brook Dudley offers sexually transmitted infection (STI) testing, contraception and emergency contraception as well as counselling and support in improving young people’s health and well-being. Brook Dudley did not carry out termination of pregnancies at the service. The service operated on a hub and spoke model which meant there was a main clinic in Dudley town centre and six spoke clinics in local colleges.

Young people could drop into the service at a time convenient to them. Brook Dudley was open four days a week. Opening hours were from 3.30pm until 8pm on a Monday and Tuesday and from 12pm until 4pm on a Friday and Saturday.

Updated 8 June 2017

We carried out an announced comprehensive inspection on 25 October 2016 to ask the service the following key questions; Are services safe, effective, caring, responsive and well led?

Our Key findings:

W e found the following areas of good practice:

• The registered manager was the safeguarding lead for the service and was trained to the required level 4 in safeguarding children and young people.
• There were processes in place to act on historic safeguarding concerns.
• Staff treated young people with dignity and respect and engaged with young people in a caring manner.
• Young persons' records were complete, contained relevant information, and were up-to-date.
• Staff completed risk assessments in relation to young people and these formed part of the patient history.
• Areas were visibly clean; staff washed their hands appropriately between each patient interaction and used personal protective equipment.
• Systems were in place to monitor medications with patient group directives (PGD) available when required.
• Staff followed appropriate assessment guidelines when supporting people under 16.
• Staff respected young people’s confidentiality when in the reception area.

However;

We identified regulations that were not being met and the provider must:

• The provider must ensure that all clinical staff who contribute to assessing, planning and evaluating the needs of the child or young person are trained to safeguarding at level three as recommended in the safeguarding children and young people : roles and competencies for health care staff by the Royal College of Paediatrics and Child Health, March 2014.
• The provider must ensure infection control training is completed by all staff providing direct clinical care and involved in specimen collection and transportation.
• The provider must ensure there is a local risk register in place to provide overview of local risks.

There were areas where the provider could make improvements and should:

• The provider should ensure that staff are up-to-date with their annual mandatory training and appraisals.

• Ensure that all incidents are recorded and their severity assessed when they meet Brook young persons incident reporting criteria.

• Consider a local audit programme with action plans, mitigations and specified timescales when the service is not meeting agreed standards.

• Consider how the “Mental Capacity Act 2005” and its codes of practice may be relevant to the service and how the service is complying with the principles of the Act.

• Ensure electrical equipment is tested for safety as per manufacturer’s guidelines.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements. We also issued the provider with three requirement notice(s) that affected Brook Dudley. Details are at the end of the report.

Updated 8 June 2017

Sexual health services

Inspected but not rated

The registered manager was the safeguarding lead for the service and was trained to the required level 4 in safeguarding children and young people.

There were processes in place to act on historic safeguarding concerns.

Staff treated young people with dignity and respect and engaged with young people in a caring in manner.

Young persons' records were complete, contained relevant information, and were up-to-date.

Staff completed risk assessments in relation to young people and these formed part of the patient history.

Areas were visibly clean; staff washed their hands appropriately between each patient interaction and used personal protective equipment.

Systems were in place to monitor medications with patient group directives (PGD) available when required.

Staff followed appropriate assessment guidelines when supporting people under 16.

Staff respected young people’s confidentiality when in the reception area.

However, we also found the following issues that the service provider needed to improve:

Not all staff who contributed to assessing, planning, and evaluating the needs of a child or young person were trained to safeguarding at level three.

There was no local risk register in place to provide overview of local risks.

The provider could not demonstrate that clinical staff had received an annual infection control update in the last 12 months.

Incidents were not always reported or shared with staff to improve learning.

Incidents were not always graded to determine if risks were minor, moderate or serious.

Only 75% of staff had an appraisal during the last year; this was lower than Brook Young People’s national target compliance rate of 85%.

The service was unable to provide evidence that portable appliances had been safety tested.

There was no training for staff on the ‘Mental Capacity Act, 2005’ and how it applied to young people under 25 years of age.

There was poor communication between the registered manager and the clinical manager.

Training documentation was not always consistent, up-to-date and easily accessible to all members of the management team.