We carried out this announced inspection on 11 and 12 December 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a CQC inspector who was supported by a second CQC inspector and a specialist professional advisor.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

These questions form the framework for the areas we look at during the inspection.

Our key findings were:

• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
• The service had systems to help them manage risk.
• The staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
• Systems were in place to support multi-agency working
• The service had thorough staff recruitment procedures.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• The appointment/referral system met patients’ needs.
• The service had effective leadership and staff told us they felt well supported and listened to.
• Staff felt involved and supported and worked well as a team.
• The service asked patients for feedback about the services they provided.
• The service staff had systems to deal with complaints positively and efficiently.
• The staff had suitable information governance arrangements.
• The service was clean and facilities are well maintained.
• The staff had infection control procedures which reflected published guidance.

There were areas where the provider should make improvements. The provider should:

• Develop a workplan that sets out aspirations and service developments.
• Implement an induction programme appropriate to the team member that measures progress on competencies.
• Ensure the Crisis Support Workers have consistent access to regular reflective practice
• Consider ways to ensure children, young people and families are able to feedback on any leaflet produced for this age group.
• Assess and mitigate risks associated with upstairs windows
• Ensure Care UK have an overriding Consent Policy to lay out the organisational strategy for management of consent