• Residential substance misuse service

Archived: Withersdane

Withersdane Hall, Coldharbour Lane, Wye, Ashford, Kent, TN25 5DA

Provided and run by:
Brou Limited

All Inspections

11, 12 and 19 July 2017

During an inspection looking at part of the service

We do not currently rate independent standalone substance misuse services.

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

  • During our inspection in August 2016, we found the service in breach of regulation 12 of the Health and Social Care Act 2014 concerning lack of call alarms in client bedrooms. The service had installed an alarm in only one bedroom at the time of our inspection.

  • It was part of a requirement notice from our comprehensive inspection that the service conducted regular fire drills and had relied on false alarms to conduct drills. The service had recently commenced fire drills and had conducted their first scheduled drill on 3 July 2017.

  • At the comprehensive inspection in August 2016, we found that not all staff were competent to administer emergency medicines. During this inspection, three staff told us they did not feel competent or confident to administer this medicine.

  • The service stored emergency medicines including naloxone, epipens and buccal midazolam. Buccal midazolam is a prescription only medicine that only clinical staff who have agreed to work within the terms of a patient group direction can administer. However, we saw that some staff had been trained to administer buccal midazolam who did not meet the legal framework to do so. Inspectors raised this with the clinical manager who acted on this information.

  • Rotas reviewed showed that there had been no nursing cover for part or all of 10 of the 14 days between 26 June and 9 July 2017. The rotas recorded that the service had arranged cover for six shifts between 8pm and 8am during this period. However, there was no nurse available for seven shifts between 8am and 8pm and five shifts between 8pm and 8am.  Volunteers from the sober living community were included in night staff numbers. The rotas demonstrated that there were only two health care assistants available after 10pm on four occasions during this period. The Group Clinical Director has confirmed that since the inspection, the service has recruited a nurse and confirmed that there will be three permanent nurses in post from the end of September 2017.

  • At the comprehensive inspection in August 2016, we issued a requirement notice that the service should implement a more robust system for incident reporting. During this inspection there was no evidence of a formal process to collate, analyse or share learning from incidents.

  • We reviewed 11 prescription and administration charts. Staff had recorded allergies on prescription charts. However, some charts contained a number of administration gaps, which represented missed doses of medicines. This also included medicines which should not be stopped abruptly. Additionally, it was not always possible to tell the reasons for missed doses as staff did not consistently record this information.

  • Clinical staff completed a pre admission assessment form and medical assessment for all clients. However, the assessment process did not include questions about children as recommended in the drug misuse and dependence UK guidelines on clinical management and as identified in our report following the comprehensive inspection in August 2016. The assessment process did not formally demonstrate consideration of Wernicke Korsakoff syndrome, which had also been identified at the last inspection. Wernicke’s encephalopathy is a disorder that affects the function of the brain. It usually develops suddenly, often after abrupt and untreated withdrawal from alcohol.

  • Some people were self-administering medicines but this did not match the service’s policy.

  • Our inspection in August 2016 identified that staff should receive regular one to one performance management meetings. Only two of the staff interviewed during this inspection said that they received regular performance management meetings.

  • The service had updated their admission policy to include exclusion criteria since our last inspection. The policy included information about categories of clients that the service would not provide treatment to and actions for staff where there may be concerns that the service could not meet a client’s needs. However, the criteria was basic and did not provide detailed information. For example, it did not include the minimum body mass index for clients with an eating disorder that the service would consider for treatment.

  • The service relied on sending information to staff via emails which were not saved on the electronic framework.

  • We found that staff had not reported four incidents that required notification to CQC.

  • Data provided by the service recorded that six of the 27 volunteers did not have a disclosure barring service check in place.

  • After our comprehensive inspection in August 2016, we issued a requirement notice that the service should make sure that their statement of purpose (SOP) contained accurate information. No changes had been made to the SOP reviewed during this inspection.

  • The service did not have a Duty of Candour policy. However, since being raised by inspectors, the service was developing a policy.

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

  • Risk assessments were comprehensive and detailed. The clinical manager reviewed risk assessments and risk management plans to make sure they were accurate and up to date.

  • There was an appropriate range of emergency medicines, including oxygen that were within their expiry dates. Staff checked emergency medicines weekly.

  • The service had recruited a doctor who was on site during normal working hours. Staff could contact the doctor outside of normal working hours if required.

  • We reviewed 14 client records which were comprehensive and detailed. Care plans were individualised and staff regularly reviewed progress with clients. Staff knowledge of clients was good.

  • An external pharmacist visited Withersdane every other week to help screen prescription charts and undertake medicines management audits.

  • Staff followed the service’s safeguarding policy and knew when a safeguarding referral would be appropriate.

  • The clinical manager had introduced guidance of staff responsibilities during a client’s treatment journey.

  • The process to audit client files was effective. The clinical manager reviewed all client records to make sure that they were accurate and up to date prior to attending the clinical management meeting.

  • We observed a clinical management meeting. The meeting allowed staff to contribute in decisions made about the care of clients.

  • We found that the service had acted on the following concerns identified during our inspection in August 2016:

  • The service had acted on the requirement that staff must have access to emergency medicines quickly and without delay. The service had increased the set of emergency medicines to two and located them in different site areas to allow staff quick access.

  • The service had reviewed the process for staff administering medicines since our last inspection. Staff administered medicines in a dedicated area away from the clinic room to avoid interruption.

  • At our inspection in August 2016, we issued a requirement notice that the provider must ensure there were robust systems in place to ensure that client records were up to date and stored appropriately. During this inspection, we saw that this had been addressed.

  • At the last inspection we identified that the provider should encourage staff to work more as a multi-disciplinary team. We saw that the provider had created one large office for all staff, to encourage multi-disciplinary working. Staff told us that communication between the three different roles had improved since this office had been introduced.

8 to10 August and 17 August 2016

During a routine inspection

We do not currently rate independent standalone substance misuse services.

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

  • The service did not have a written admission or exclusion criteria. This meant that the service could assess and admit high risk clients whose needs could not be met by the service.
  • The service accepted referrals for clients with eating disorders. We were told that clients would not be accepted into the service if their body mass index (BMI) was 16 or less. The service did not employ specialist staff to manage the risks associated with somebody with a BMI of 16 or under. We were told that clients with eating disorders would only be considered where there was comorbidity with substance misuse. However, there was no documentation to support this.
  • The service did not contact a client’s GP or other professionals prior to a client’s admission in order to gain a comprehensive history of a client’s physical and psychological health.
  • Staff had not received training to administer emergency medicines. The manager told us that the service was arranging training for staff.
  • The service did not have a patient group direction (PGD) that allowed nurses to administer midazolam and the midazolam was not prescribed on the prescription charts. This meant that staff would not be able to legally administer the midazolam in an emergency. Midazolam can be used to treat alcohol related seizures.
  • Staff checked the emergency medicines weekly. We saw this process and the bag matched its stated contents. However, the service did not record these weekly checks in line with their policy.
  • There were inconsistencies of reporting incidents including safeguarding.
  • While the external pharmacy service audited the provider and identified medicine errors, there were some inconsistencies in how the Withersdane staff reported and analysed medicine incidents.
  • Staff shared information regarding client’s clinical needs and updates via email. However, staff did not always upload emails regarding clients onto the client’s electronic record. Therefore access to information was not always available.
  • The service did not have a medical assessment proforma which meant that the detail in the assessments was variable.
  • Risk assessments and management plans were inconsistent in their detail. However, staff documented relapse prevention work in clients care plans.
  • We saw no evidence of multi-agency working with other professionals involved in clients care.
  • The service did not measure outcomes or performance in order to improve and develop the service.

However:

  • The service had responded to concerns from our previous inspection regarding nursing provision and had introduced 24 hour nursing cover, seven days a week.
  • The service had responded to concerns from our previous inspection and improved the medicines management.
  • The service had responded to concerns from our previous inspection regarding the environment.
  • All clients received a comprehensive pre admission assessment with a nurse. All detox clients received a pre admission assessment with a nurse and full medical assessment with a doctor.
  • The admissions process was well managed and an appointment was offered for a pre admission assessment, normally within 24 hours of the referral. Staff arranged an appointment with the doctor within 24 hours of the nurse assessment being completed. Staff gave clients a thorough orientation to the service on admission.
  • We observed staff demonstrating dignity, care and respect for clients. We saw evidence that the service was responsive to the individual needs of clients.
  • There was a wide range of activities available which included art therapy, music therapy, equine therapy and shiatsu massage.
  • All staff, excluding nurses, completed the Level 1 care certificate alongside mandatory training.
  • The service actively encouraged family and carer involvement and provided dedicated time to provide support and interventions for clients and their families.