We inspected the community children and young people service which operates from Endeavour House on 20 November 2018. Suffolk County Council provides a range of health services for children and young people aged 0-19 years, and their families living in Suffolk. We inspected this service as an unannounced focused inspection. The last inspection was completed in 2017 and we did not rate the service at that time

6.

When we inspected in 2017 we issued a requirement notice to the provider for failing to provide us with evidence of compliance to Regulation 17 (1) (2) (a) (b). This was because systems and processes were not established nor operated effectively to ensure compliance with the requirements of this regulation. Pre-employment records were not kept up to date and not all staff could access these.

Our key findings were as follows:

• All 0-5 years outcomes reviewed showed that general levels of performance had improved
• A monthly quality dashboard was closely monitored to support agreed targets
• Staff had completed annual appraisals
• Clear processes and systems were now in place.
• Policies and procedures were reviewed and referenced to national guidance and easily accessed by staff.
• Staff records reviewed were complete and contained completed checks.

We found the following areas of good practice:

• Staff provided evidence based care and treatment that followed national guidance. Quality checks of electronic records assured staff that children and young people were on the correct treatment pathway.
• The service promoted and supported breast feeding. The staff had achieved level one accreditation for Baby Friendly initiative (UNICEF)
• Staff supported children and young people to live healthier lives
• Staff had the appropriate skills, knowledge and experience to deliver effective care and treatment
• There was effective multidisciplinary team work across the service. Staff worked to maintain the child or young person at the centre of their care.
• Staff were aware of their responsibilities to seek individual patient consent, in line with current legislation.
• There was a clinical audit programme across the service to assure senior staff of the effective and safe care delivered to children and young people.
• Staff knew who their managers were and what they were accountable for. Managers knew about the quality issues, priorities and challenges. All staff had a clear knowledge of their role and implemented the vision and purpose of the service.
• Staff described the service’s culture as being open and transparent with managers who were visible, supportive and approachable. The staff were actively engaged in the planning and delivery of the service and were confident in raising any concerns.
• The service had governance, risk management and quality measures to improve patient care, safety and outcomes.
• The patient’s feedback about the service was obtained through the monthly Friends and Family Test key question, asking if they would recommend this service to friends and family.
• The service had checked systems and processes were in place for their compliance with the General Data Protection Regulation (GDPR) introduced from May 2018.
• Staff were supported with opportunities for further learning and development. Several staff members described how they had developed and progressed within the organisation. Managers spoke of staff development.

On the basis of this inspection, we found the service was now compliant with Regulation 17 and there were no further areas for improvement.

Amanda Stanford

Deputy Chief Inspector of Hospitals 

on behalf of the 

Chief Inspector of Hospitals 

During our inspection we visited the administrative office and one of the locality offices of the service. We met with the management team and eight of the staff employed by the service but were unable to talk to anyone who was receiving treatment from them at that time.

The service provided treatment to children and young adults throughout Suffolk including the health visiting services, school nursing service and the ‘looked after’ children service. These were children who were in the care of their local authority.

The staff we spoke with detailed the assessment and care process which ensured that the needs of the person concerned were identified and showed how they would be met. We looked at electronic care records from each area. These were clear and up to date.

We discussed the quality measures in place which monitored treatment performance, staffing, safeguarding and complaints and provided a detailed picture to the management team. We found that these were effective.