Verve Health

Independent Healthcare Org · East

Overall Rating
Inadequate Last inspected 12 December 2022
Domain Ratings
Safe
Inadequate
Effective
Requires Improvement
Caring
Requires Improvement
Responsive
Inadequate
Well-led
Inadequate

View Full CQC Report

21 must-do actions
2 should-do actions

Must-Do Actions (21)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Caring
The service must involve service users in care planning and risk assessment.
Regulation 9 HSCA(RA) Regulations 2014 Person-centred care
Staff did not always involve service users in care planning and risk assessment.
Must Do
Well-led
The service must ensure managers have the skills and relevant operational training to perform their roles.
Regulation 17 HSCA(RA) Regulations 2014 Good governance
managers at the service lacked recent training in areas which required vital operational knowledge such as safeguarding.
Must Do
Safe
The service must ensure that staff complete a comprehensive assessment and care plan and maintain accurate risk assessments for each service user and that staff complete effective risk management plans to reduce identified risks.
Regulation 12 HSCA(RA) Regulations 2014 Safe care and treatment
Staff did not always assess and manage risks to service users and themselves well... risk assessments did not always contain accurate information on risks to service users. We found that two of these risk assessments did not contain accurate information about the known risks of service users or information about …
Must Do
Well-led
The service must ensure governance systems and processes are in place to assess, monitor and improve the quality and safety of the service.
Regulation 17 HSCA(RA) Regulations 2014 Good governance
Our findings from the other key questions demonstrated that governance processes were not operating effectively at the service and performance and risk were not always managed well.
Must Do
Safe
The service must ensure that staff complete personal discharge plans and provide harm reduction advice for all service users leaving the service in order to safely support service users when they return to the community.
Regulation 12 HSCA(RA) Regulations 2014 Safe care and treatment
Staff did not plan or manage discharge well. The service had no alternative care pathways or referral systems for people whose needs it could not meet... Staff were not completing discharge plans to reduce potential harm to service user’s upon discharge from the service. Staff did not always direct service …
Must Do
Effective
The service must ensure they have enough suitably competent, skilled and experienced clinical staff.
Regulation 18 HSCA(RA) Regulations 2014 Staffing
The service had enough staff, however not all staff were familiar with service users and not all staff received basic training to keep service users safe from avoidable harm. Staff teams did not always have access to the full range of specialists required to meet the needs of service users …
Must Do
Effective
The service must ensure staff including those who work at the service but are not directly employed have the right skills and training to meet the needs of the service users in their care and that they receive a full induction to the service before they start work, ongoing training and that staff receive regular appraisals, supervision and access to team meetings.
Regulation 18 HSCA(RA) Regulations 2014 Staffing
not all staff received basic training to keep service users safe from avoidable harm. Managers had not ensured that agency staff received a full induction to the service prior to working. Managers had not ensured that all staff had the range of skills needed to support service users in recovery. …
Must Do
Safe
The service must ensure they use systems and processes to safely prescribe, administer and record medicines and that the clinic room and medication is secure.
Regulation 12 HSCA(RA) Regulations 2014 Safe care and treatment
Staff did not always prescribe, administer, store or record medications safely. All medicines were stored in a lockable cupboard within a locked treatment room. However, the keys to both the room and the medicines cupboard were not secure. The fridge temperatures showed the fridge was not suitable for storing medicines …
Must Do
Effective
The service must ensure that staff are trained in Mental Capacity Act and have an understanding of the five principles and how to apply them and that service users have an opportunity to give consent to treatment when they are no longer under the influence of illicit substances.
Regulation 11 HSCA(RA) Regulations 2014 Need for consent
Staff did not always understand the service’s policy on the Mental Capacity Act 2015 and were unsure on what to do if a service user’s capacity to make decisions about their care might be impaired. Staff were not ensuring adequate consent had been obtained with service user’s in treatment. Service …
Must Do
Safe
The service must ensure service user safety incidents are managed, staff report incidents appropriately and managers investigate incidents and share lessons learned with the whole team.
Regulation 12 HSCA(RA) Regulations 2014 Safe care and treatment
Staff did not report all incidents appropriately. Managers did not always investigate incidents thoroughly and learning was not always shared with the whole team and wider service.
Must Do
Well-led
The service must ensure that staff are able to escalate concerns relating to medicines to an appropriately clinically trained and competent individual.
Regulation 17 HSCA(RA) Regulations 2014 Good governance
staff told us that they were not always able to get hold of the nurse prescriber who worked at the service, due to them only working certain days of the week and staff were hesitant to call the doctor. This posed a risk to service users whom may have required …
Must Do
Safe
The service must ensure staff are applying the duty of candour when things go wrong.
Regulation 20 HSCA(RA) Regulations 2014 Duty of candour
Staff were not applying the duty of candour if and when things went wrong. For example, incident reports did not identify situations where the duty of candour would apply, and there was no evidence demonstrating that service users were provided with an apology or explanation.
Must Do
Well-led
The service must ensure adequate medical governance processes and systems are in place to monitor and assess the practice and competence of clinical staff and ensure the safety of medical practices.
Regulation 17 HSCA(RA) Regulations 2014 Good governance
Managers had not ensured adequate monitoring of performance to ensure medical detoxifications were safe for service users. The service did not have adequate medical oversight to ensure concerns were identified and actions taken to prevent harm to service users.
Must Do
Well-led
The service must ensure that managers record and monitor key information used to assess compliance in order to improve the quality and safety of the service, such as training and supervision compliance.
Regulation 17 HSCA(RA) Regulations 2014 Good governance
it was not clear how information from completed audits was being used to improve quality of care. other processes still required further improvement in order to safely support service users. For example, staff required training in safeguarding and specific drug and alcohol training. Audits of medication and prescription records remained …
Must Do
Well-led
The service must ensure that staff are aware of how to use the whistleblowing process.
Regulation 17 HSCA(RA) Regulations 2014 Good governance
Staff were not always clear on how to use the whistleblowing process or who to approach if they felt unable to raise concerns if they did not feel able to approach managers.
Must Do
Safe
The service must ensure that service users undergoing medical detoxification are appropriately monitored during their detox programme, including respiration rates and temperatures.
Regulation 12 HSCA(RA) Regulations 2014 Safe care and treatment
People were not adequately monitored during their detoxification programme. Respiration rate and temperature were not monitored. Both parameters are important to detect clinical deterioration or oversedation. Staff had not been trained to monitor respiration rate.
Must Do
Safe
The service must ensure that regular fire drills are completed to ensure service users and staff are able to safely vacate the building in the event of an emergency.
Regulation 12 HSCA(RA) Regulations 2014 Safe care and treatment
The service had not ensured regular fire drills were completed. The last fire drill occurred in 2021.
Must Do
Safe
The service must ensure that service user records are legible and provide a contemporaneous account of all contact with the service user and relevant information in order to safely support each service user and manage risk.
Regulation 12 HSCA(RA) Regulations 2014 Safe care and treatment
Staff records of service user’s care and treatment were fragmented. Records were not always clear, up-to-date or easily available to all staff providing care. Service user notes were in paper form and records for each service user were fragmented between different folders within the service. Staff notes were not always …
Must Do
Well-led
The service must create a risk register to effectively record and mitigate against key risks to the service.
Regulation 17 HSCA(RA) Regulations 2014 Good governance
The service did not hold a risk register however they had introduced an ‘improvement plan’, following our past inspection. It was not evident that this plan was reviewed appropriately, and it was not clear who was responsible for the individual actions of the plan.
Must Do
Safe
This service must ensure that service users have Personal Emergency Evacuation Plan’s (PEEPs) in order to safely support them to evacuate the building in an emergency.
Regulation 12 HSCA(RA) Regulations 2014 Safe care and treatment
The upstairs fire escape route was not signposted and there were trip hazards along the route. We observed one service user with reduced mobility who was struggling to walk around the service. Staff had not planned for the service users care needs in order to adequately support him in moving …
Must Do
Safe
The service must ensure staff understand how to protect service users from abuse, and how and when to make a safeguarding referral.
Regulation 12 HSCA(RA) Regulations 2014 Safe care and treatment
Most staff understood how to protect service users from abuse. The service were not working with the local authority and reported to us that there had been one incident which warranted a safeguarding referral. Not all staff had training on how to recognise and report abuse. Not all staff received …

Should-Do Actions (2)

Recommended improvements to enhance service quality.

Should Do
Effective
The service should ensure that regular full staff meetings, staff multi-disciplinary meetings and handovers occur in order to discuss service user needs, share relevant key information and share learning or areas for improvement.
Should Do
Effective
The service should ensure collating outcomes of treatment to establish effectiveness.

Previous Inspection (12 December 2022)

Rating: Inadequate Type: Focused inspection Actions: 13 must-do
2 resolved 10 repeated 1 partial
Location Details
CQC ID: 1-11122366397
Local Authority: Norfolk
Region: East
Inspection Report
Type: Follow-up inspection
Date: 21 March 2023
Rating: Inadequate
Actions: 21 must-do , 2 should-do
AI-extracted 17 Feb 2026