Broadway Lodge

Updated 13 November 2018

Broadway Lodge is a non-profit making organisation and registered charity established in 1974. The service provides residential addiction treatment, counselling and support services for adults. Broadway Lodge offers several treatment programmes that include detoxification, residential rehabilitation and recovery support for people living at home. It provides accommodation for persons who require treatment for substance misuse and treatment of disease, disorder or injury.

Broadway Lodge offers a range of services that include aftercare and a structured residential day programme seven day a week. Clients attend these as part of their recovery. The service had 35 clients admitted at the time of the inspection.

Statutory organisations fund the majority of clients but it also accepts those who wish to fund themselves.

The service had a registered manager in post. A registered manager is a person who has registered with the CQC to manage a service and they have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations. Broadway Lodge is part of Broadway Lodge Limited.

We previously inspected Broadway Lodge from 5 to 7 April 2016. We issued five requirement notices following this inspection and told the provider it must:

The provider must ensure that people admitted for detoxification from opiates have an individual care plan detailing the care and treatment staff must provide to ensure risks to their health and safety are managed appropriately.

The provider must ensure risk assessments relating to health, safety and welfare of people using the services are completed and reviewed regularly by people with the qualifications, skills and competence to do so. Risk assessments should include plans for managing risk

The provider must ensure incidents are reviewed and thoroughly investigated by competent staff and monitored to make sure that action is taken to remedy the situation, prevent further occurrences and make sure that improvements are made as a result.

The provider must ensure records are accessible to authorised people as necessary to deliver clients care and treatment in a way that meets their needs and keeps them safe.

The provider must ensure policies and procedures are in place for anyone to raise concerns about their own care and treatment or the care and treatment of people they care for or represent. The policies must be in line with current legislation and guidance and staff must follow them.

The provider must ensure staff receive regular appraisals of their performance in their role from an appropriately skilled and experienced person and any training, learning and development needs should be identified, planned for and supported

On the 4 April 2018 we carried out a focussed inspection to follow up on the previous requirement notices. Following that inspection, we were satisfied that the above requirement notices were met apart from Regulation 17(2) (c). Therefore, we issued another requirement notice which was as follows:

The provider must ensure staff have access to records contain all relevant information that need to be aware of risk and to deliver client care and treatment in a way that meets their needs and keeps them safe.

Updated 13 November 2018

We rated Broadway Lodge as good because:

• Staff treated clients with kindness, dignity and respect. Staff demonstrated an understanding of the individual needs of clients.
• The provider had addressed the issues we raised at our last inspection. Records were accessible to all staff. The provider held records in paper and electronic format. The provider was in the process of moving to an electronic record keeping system with a completion date of end of this year.
• At our comprehensive inspection in 2016 we found that records were not accessible to authorised people as necessary to deliver clients care and treatment in a way that met their needs and kept them safe. During our focused inspection on 4 April 2018, we found that staff did not have access to records contain all relevant information that need to be aware of risk and in order to deliver clients care and treatment in a way that meets their needs and keeps them safe. This was a breach of regulation 17 (2)(c). At this inspection we found this requirement had been met; staff told us and we saw that records were accessible to all staff. The provider held records in paper formats and these records were also stored on computers. We were told the provider was in the process of moving to electronic record keeping system with a completion date of the end of this year.
• Staff screened clients prior to admission to ensure the service could meet their needs; they completed care plans with clients upon admission. Staff enabled clients to access physical healthcare including GPs, dentists and hospital appointments.
• All clients had a risk assessment. There was an initial risk assessment followed by a further ongoing one. The initial risk assessment was robust and comprehensive. The ongoing risk assessment was more standard with less details.
• The service was fully staffed. Staff received regular supervision and they attended team meetings and handovers. Staff told us morale was very good, they worked well as a team and supported each other.
• Staff ran a weekly house meeting for clients to raise concerns and complaints informally. Clients knew how to complain. Staff actively sought the opinions of clients. There were systems to record, review and discuss complaints and incidents in place and there was evidence of change in response to these.
• The service had a range of facilities for clients including an art room, a chapel, extensive grounds, table tennis and yoga equipment. There were a range of activities for clients to take part in including art, gardening, games, meditation, reiki, acupuncture and shopping trips. The provider supported clients to access community based substance misuse support groups.
• The provider followed national best practice guidelines treatment such as National Institute for Health and Care Excellence guidelines (NICE). Staff we spoke with told us they used the Department of Health drug misuse and dependence UK guidelines on clinical management (also known as the ‘Orange Book’).

• The provider had established systems and processes to monitor and improve the safety of the environment. The provider completed regular risk assessments of the environment and action plans were developed based on the risks identified.

• The provider had effective systems and processes in place to ensure its workforce were equipped to deliver treatment. Staff had an annual appraisal and six-monthly reviews.

• The service had a dedicated registered manager. The registered manager had been working in this role for several years. Leaders and managers were visible and experienced in working in substance misuse.

However:

• Not all clients had a discharge plan and were involved in the planning of their discharge.
• Staff did not monitor the temperature of the clinic room environment where they stored medicines to ensure they were kept within the correct range.

Updated 13 November 2018

Broadway Lodge offers a number of treatment

programmes that include detoxification, residential

rehabilitation and recovery support for people living at home.