We rated SMART Wokingham as requires improvement because:

• The service has not had a registered manager since August 2018. At the time of our inspection visit, the provider was finalising arrangements for which individual it would nominate for the CQC registration process. CQC requested that the provider confirm it’s plans for registering a new manager without further delay. The provider subsequently confirmed that the area manager had commenced the registration process.

• Staff told us that management issues within the service had led to poor staff retention levels. Staff turnover during the 12-month period to 09 January 2019 was over 100%. Staff stated that this high turnover led to the service being short-staffed and clients receiving poor continuity of care.

• Clients reported that individual and group sessions had been cancelled due to staffing shortages. Some staff expressed a feeling of anxiety due to inadequate staffing levels and the workload pressures that placed upon them.

• Risk assessments we reviewed did not contain a risk management plan in relation to potential risks associated with an unexpected exit from treatment.
• The provider had not conducted any water tests for the Legionella bacteria since it took over the running of the service in 2014. Following our inspection the provider confirmed that a Legionella risk assessment and water sample testing had been completed within two weeks and a plan was in place for monthly water temperature tests and an annual Legionella risk assessment to take place.
• None of the eight care records we reviewed contained a copy of the client’s medical history from their own GP; none contained evidence of the client’s initial medical assessment within the service; and, only four contained some evidence of ongoing physical health assessments.
• Clients told us they were unhappy with the quality of soundproofing within the building. They said it could be distracting when they were trying to focus on their session, when there was noise within the reception area. In response to the concerns raised by clients, staff tried to minimise the number of people in the vicinity of meditation sessions, which were adversely affected by noise outside the room.
• Some staff we spoke with expressed anxiety about raising concerns, for fear of negative consequences.

However:

• Client records contained recovery plans written with the joint input of the clients and their support worker. Recovery plans were holistic, addressing all the identified needs of each client.
• Staff attended team meetings, that occurred an average of twice per month, during which staff discussed a wide range of topics, including learning from recent incidents. Staff received a supervision session every four to eight weeks. Managers addressed staff performance issues in supervision.
• Staff demonstrated that they had effective working links with local external services such as community mental health teams, housing providers, children and family services, social work and criminal justice agencies. Staff referred clients to partner agencies as appropriate.
• Staff adapted appointment times to meet the needs of clients. The service was open two evenings per week and had early morning clinic slots available, to give working clients additional opportunity to attend appointments and therapy sessions.
• Staff provided a joint monthly drop in session for clients, with a local homelessness charity, a social housing provider and a community mental health team. The venue for the session rotated between the partner agencies. The aim was to provide clients with a one-stop shop advice forum.

We do not currently rate independent standalone substance misuse services.

We found the following areas of good practice:

• There were enough suitably qualified, trained and competent staff to provide care to a good standard. Staff were confident in how to report incidents and they told us about changes they had made to service delivery as a result of feedback, following incidents.
• Clients’ risk assessments and plans were robust, recovery focussed and person centred. The assessment of clients’ needs and the planning of their support, treatment and care was thorough and individualised. Staff considered the needs of clients at all times.
• SMART had a strong focus on recovery, treatment, empowering clients and ensuring their wellbeing. All staff were committed to the vision and values of the organisation. Staff were motivated to ensure the objectives of the organisation and of the service were achieved. The provider’s senior management team brought strong leadership to the service and were available to both clients and staff.
• Governance structures were clear, well documented and followed. These provided control measures for managers so that they were able to assure themselves that the service was effective and being provided to a good standard. The managers and their team were fully committed to making positive changes to improve the quality of the service provided to clients. For example, through the use of regular audits. The service had clear mechanisms for reporting incidents of harm or risk of harm and we saw evidence that the service learnt from when things had gone wrong.

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

• The environment needed some repairs and attention. For example, cleaning was required in the kitchen and part of a fire exit was blocked with rubbish bags. The ceiling in the reception area was stained from a previous leak.
• Not all staff were familiar with the Duty of Candour policy.

We do not currently rate independent standalone substance misuse services.

We found the following issues that the service provider needs to improve:

• The service did not report the unexpected death of a client in 2015 to the Care Quality Commission.

• Staff did not receive specialist training in substance misuse but SMART have recognised this and a robust action plan was in place to improve training for all staff and volunteers.

• Overdose prevention training was not provided for staff, clients or carers but will be provided by the recently accredited specialist, level 3 training for staff working with substance misuse and complex needs.

• SMART has provided training to all staff for Mental Capacity Act 2005 in the form of a workshop during a team meeting. Some staff was still not confident to provide mental capacity assessments and further support is required.

• Not all staff had received adult safeguarding training; 62% of staff had received local authority training in Adult Safeguarding Level One which included the lead for safeguarding within the team.

• Not all of the volunteers working at the service had been screened by the Disclosure and Barring Service (DBS) and the prescribing doctor had not been revalidated.

• Carers told us that they would have liked more advice, guidance and support in the early stages of their relative’s treatment to enable them to support the client.

• Some areas of the building appeared unclean and in need of repair. There was no system in place to check what cleaning had been done.

• Risk assessments did not include a plan for unexpected treatment exit.

• There was a lack of staff clarity around the service’s complaint’s procedure.

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

• The prescribing doctor at the service prescribed medicines approved by National Institute for Health and Care Excellence (NICE) for reduction from opiates. The service prescribed dosages within the range recommended by the British National Formulary.

• Shared information from the service to the client’s GP kept the GP informed and updated regarding substance misuse medicine the service had prescribed.

• Staff asked clients about their physical and mental health as part of the comprehensive drug and alcohol assessment.Staff liaised with the client’s GP if further medical information was needed or if a physical intervention was required before treatment could begin.

• The policies we looked at were thorough and included references to NICE. There was a good system in place to ensure that staff have read the policy.

• There was good evidence of recovery plans in place, holistic, personalised and that clients were offered a copy.

• Risk assessments were present and reviewed regularly, every twelve weeks or more frequently if necessary.

• SMART Wokingham had introduced a ‘skills level one employability course’ for clients in response to client feedback that there was not enough support for education or employment. Following completion clients could go on to become a volunteer at SMART.

• Clients and carers told us that staff were compassionate and committed; we observed caring and respectful interactions between staff and clients.

• The recovery facilitators were also leads within the service as a point of contact for colleagues, such as a criminal justice lead, and had developed good links with external organisations.