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Inspection Summary


Overall summary & rating

Missing

Updated 9 September 2016

We do not currently rate independent standalone substance misuse services.

We found the following issues that the service provider needs to improve:

  • Care records did not contain detailed information that addressed the needs of each individual and had limited space for clients to identify their own strengths and resources. This meant staff did not design care or treatment with a view to achieving the client’s preferences and ensuring that staff met the client’s needs.

  • All clients have an electronic client data management system record. Staff regularly updated this for therapeutic interventions. Staff maintained medical records separately for all clients. All members of the medical team have access to the client data management system records. All counsellors can access the medical records by visiting the medical offices. Some staff told us they did not always check the records and relied on staff handovers to keep up-to-date with care and treatment.

  • The provider did not assess the environmental risks to the health and safety of clients who received care and treatment. This meant that staff could not use the environmental risk assessment to make required adjustments, for example, to the premises or equipment, which could affect aspects of care and treatment.

  • The provider had not thoroughly reviewed all incidents reported to make sure that staff took action to remedy the situation. This meant staff could not prevent further occurrences and make sure that staff made improvements as a result.

  • The provider had an appraisal system. However, this was not robust. The manager had not identified staff development, set goals or followed up on disciplinary actions. This meant that the manager could not monitor staff competence.

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

  • Clients described feeling supported by staff; clients said staff treated them in a dignified and respectful manner.

  • Clients receiving treatment at Broadway Lodge felt safe. The provider had an understanding of client clinical risks. Procedures were in place to ensure safe administration of medication.

  • The provider complied with the guidance of the National Institute of Health and Care Excellence (NICE) and Public Health England. They offered a range of therapeutic activities that included Cognitive Behavioural Therapy.

  • Staff provided individualised methods of supporting clients’ recovery, for example, information provision for non-English speakers. There was a complaints management policy within the organisation and staff understood and worked within the duty of candour.

Inspection areas

Safe

Missing

Updated 9 September 2016

We do not currently rate standalone substance misuse services.

We found the following issues that the service provider needs to improve:

  • The provider did not have an up to date environmental risk assessment

  • managers had not always evidenced lessons learnt and changes to practice following incidents

  • care records did not contain detailed and updated information that addressed the clients’ risk.

However, we found the following areas of good practice:

  • Staffing levels were safe and there were processes in place to ensure safe medicines management

  • safeguarding procedures were robust and staff understood them.

Effective

Missing

Updated 9 September 2016

We do not currently rate standalone substance misuse services.

We found the following issues that the service provider needs to improve:

  • Staff stored some records on paper and some electronically; staff said having two systems makes it difficult for them to locate and access records

  • managers did not provide evidence of a robust appraisal system

  • some care plans completed by staff had limited information and were not always person centred.

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

  • Broadway Lodge completed robust admission assessments to ensure that clients admitted were suitable for the service and care provided

  • staff provided therapies that followed the National Institute of Clinical Excellence guidelines.

Caring

Missing

Updated 9 September 2016

We do not currently rate standalone substance misuse services.

We found the following areas of good practice:

  • Clients were positive about the care they received from the staff at Broadway Lodge. They felt supported by the staff team

  • staff had a high level of knowledge about the clients at Broadway Lodge; this influenced the care they provided

  • the provider allocated clients a ‘buddy’ to help them settle into the house when they were first admitted

  • clients described feeling extremely well cared for and supported by the staff

  • the provider actively sought feedback from clients to enable them to help improve the service they provided.

However, we also found the following issues that the service provider needs to improve:

  • Staff did not fully include clients when creating care plans that addressed their needs.

  • the provider had not recognised the need for an independent advocacy service and limited information was available about them.

Responsive

Missing

Updated 9 September 2016

We do not currently rate standalone substance misuse services

We found the following areas of good practice:

  • Broadway Lodge offered clients a wide-ranging activity programme that focussed on physical activity, self-reflection and gaining insight into their addiction

  • the provider had passenger lifts and disabled access bathrooms to cater for the needs of those with disabilities or mobility issues

  • staff supported clients to access places of religious worship and addressed dietary requirements that arose from religious beliefs or dietary preferences

  • staff completed discharge plans as soon as possible. Staff co-produced discharge plans with the client and their care manager.


Well-led

Missing

Updated 9 September 2016

We do not currently rate standalone substance misuse services

We found the following issues that the service provider needs to improve:

  • some staff said there was a divide between nursing staff and counselling staff, which they felt meant communication was not always consistent

  • some staff said that since the chief executive officer had stopped attending meetings they felt disconnected from the senior management team

  • managers could not evidence robust appraisals and the current model of supervision did not identify or monitor areas for staff member’s improvement or future training opportunities

  • managers had not ensured that there were robust processes in place for staff to evidence outcomes or monitor progress against agreed targets.

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

  • Staff expressed positive views about the registered manager and operations manager and felt supported by them

  • staff had attended mandatory training; there was a training matrix in place to ensure training was current and up-to-date.

Checks on specific services

Substance misuse/detoxification

Missing

Updated 9 September 2016

See overall summary