We rated Compass – Lewisham Health and Wellbeing Service as requires improvement because:

• There had been a number of managers for the service, some of whom were managing the service for a short period. Staff reported that they had not felt supported by all managers and there had been inconsistency. There had been a high turnover of staff.

• There was no record of the learning from incidents being discussed and shared with staff in the service. The provider’s incident matrix guided staff on when to report incidents. Identification and reporting of safeguarding issues and breaches of confidential information were not always reported as incidents. The incident matrix did not ensure that all events and incidents which should be reported as an incident were. The provider did not formally notify the Care Quality Commission of some incidents which it was legally required to.

• The governance system was not fully effective and did not integrate the provider’s policies with the operational safety, quality and performance of the service. Managers did not have all the information they required. There was no accessible system to have oversight of the quality, safety and performance of the service.

• The service did not have a system for collating the feedback from young people, families or carers, to identify any themes or trends. This meant an important source of information that could drive improvement was missing.

• When people made complaints about the service, these were not always recorded or responded to as complaints. Senior managers did not have detailed information concerning complaints. The complaints policy did not contain an appeals process for complainants dissatisfied with a complaint investigation or outcome.

• Patient group directions for registered nurses to dispense medicines did not include the names of registered nurses authorised to do so. They did not follow legal or best practice requirements. The provider changed these immediately and confirmed no medicines had been dispensed.

• Information for young people was not always in an accessible format. There were no age appropriate or easy read versions of important information for young people with learning disabilities or reading difficulties.

• Staff did not measure and record the room temperatures where non-refrigerated medicines were stored. The effectiveness of non-refrigerated medicines may be affected if stored above the maximum temperature of 25 degrees.

• Staff lone working procedures were not known by all staff and had not been consistently followed.

• Staff and some managers did not have a full understanding of the duty of candour.

• Staff did not have a good understanding of the Mental Capacity Act 2005.

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

• All young people in the service had a comprehensive assessment and risk assessment. These were detailed, included all aspects of young people’s lives, and included all potential risks. Young people’s wishes and preferences were explicit in their care plan and their risk management plans.

• Staff provided a range of interventions to support young people’s sexual health, emotional and substance misuse issues. The interventions provided by staff followed best practice guidance from the Department of Health and the National Institute for Health and Care Excellence.

• Staff displayed understanding, sensitivity and respect when talking about young people using the service. They provided practical and emotional support and ensured that young people were involved in, and directed, the level and type of support they needed.

• Staff were knowledgeable regarding potential risks to young people, including sexual abuse, gang involvement, child sexual exploitation and neglect.

• Staff undertook all mandatory training required. The mandatory training rate was 100%.

• Staff accompanied young people to other services for their first appointment when they required more support. This was particularly important when young people were attending adult services for the first time.