We rated Compass Milton Keynes as good because:

• All interview rooms and group therapy rooms had integrated alarm call systems. The service was clean and tidy with appropriate waste management.
• Caseloads were regularly reassessed and managed in weekly clinical team meetings and supervision.
• Mandatory training had a compliance rate of above 75% completion for every course undertaken.

• All clients received an initial assessment exploring a broad range of assessments. All new clients were given a full physical health screening during their first initial appointment.
• The service followed national guidance when assessing treatment need and prescribing medicines.
• The service held weekly clinical team meetings with the multidisciplinary staff team. We saw appropriate sharing of information within these meetings and discussions around best practice and risk.

• Staff spoke about clients in a sensitive, caring and professional manner at all times. We saw staff interacting positively with clients and they appeared responsive and respectful at all times.

• The service had a daily rota of duty workers and open access appointment system in place to see clients promptly and manage their risk. The service ran two evening clinics a week for clients who couldn’t attend in the day.

• All staff we spoke with felt supported in their role and valued as part of the team.
• Incidents were appropriately recorded, escalated and investigated.
• There was a clear clinical governance structure in place to ensure that clinical risk was escalated and managed within the service.

However,

• The service failed to notify the Care Quality Commission (CQC) of statutory notifications of changes, events or incidents that affected their service or the clients who use it. Senior staff were unaware of their responsibilities regarding notifications. A requirement notice was issued in relation to this issue. Please see ‘actions we have told the provider to take’ for more information.
• The service did not have appropriate or consistent management oversight of staff supervision levels. Senior management did not seek assurances that supervision was taking place or that missed supervision sessions were being followed up.
• The quality assurance team at the service had not undertaken quality audits of the care records for over 12 months. Team leader care record checks did not demonstrate actions taken when issues were noted and there was no system in place to address poor performance in relation to client notes.
• Recalibration dates of physical healthcare equipment was not recorded centrally. There was no oversight to ensure recalibration occurred and we found equipment requiring calibration to be over a year out of date.
• Not all risks identified in the risk assessments were included within risk management plans.
• Recovery plans were not personalised, with little evidence of client views being recorded. Not all issues identified within client assessments were addressed in recovery plans in a holistic manner.