The Care Quality Commission
  • Residential substance misuse service

Archived: Freedom Recovery Centre Limited

Overall: Inadequate read more about inspection ratings

14 Pattenden Road, Catford, London, SE6 4NQ (020) 8314 0333

Provided and run by:
Freedom Recovery Centre Limited

All Inspections

26 April to 4 May 2021

During a routine inspection

Our rating of this location stayed the same. We rated it as inadequate because:

  • The provider had not ensured the care premises, equipment and facilities were safe. Important checks relating to health and safety had not taken place. This meant staff, volunteers and clients were at increased risk of avoidable harm.
  • Staff had not received basic training to keep themselves and clients safe. Leaders had not ensured that staff and volunteers had stayed up to date with their mandatory training in areas including first aid, fire safety and medication awareness.
  • Staff did not always assess risks to individual clients thoroughly, meaning there were potential gaps in the way they managed and mitigated risks such as self-harm. At our previous inspection, there were similar issues that the provider had failed to address.
  • Staff did not engage in clinical audit to evaluate the quality of care they provided. Some aspects of care planning were out dated and did not follow national, best practice guidelines.
  • The service was not well led. Leaders had lost oversight of the service, meaning performance and quality were not well managed. We found significant failures in governance processes and systems. For example, some staff and volunteers had not been risk assessed in terms of their susceptibility to COVID-19. Audits completed on staff records did not identify this issue. As a result, the service could not be assured it had identified and protected individuals who may be at higher risk of contracting the virus.
  • Some policies and procedures had not been fully adapted to the service, were outdated or had not been implemented effectively. This included the provider’s medication management health and safety and auditing policies and procedures. This meant staff did not always have clear guidance to inform them of how to carry aspects of their role safely and effectively.
  • Leadership capacity and capability was insufficient to deliver high-quality, sustainable care. Leaders had lost oversight of the service, so performance and quality were not well managed. Where areas for improvement had been identified, the provider did not always act to rectify them.
  • The provider had failed to complete the necessary checks required for directors to ensure they were suitable for their role. These checks are legally required under the fit and proper person requirement (FPPR) within Regulation 5 of the Health and Social Care Act 2008, (Regulated Activities) Regulations 2014. The need to complete these checks had been highlighted to the service at our last inspection in December 2020.
  • Some staff and volunteers reported that the service had been under increased pressure, during the COVID-19 pandemic and since our last inspection in December 2020, and they did not always feel well supported to fulfil their roles.

However:

  • The premises was clean.
  • The team included or had access to a range of specialists required to meet the needs of clients under their care. Staff worked together as a team and with relevant services outside the organisation. Staff adapted the support they provided based on feedback from clients.
  • Staff treated clients with compassion and kindness. They actively involved clients in decisions and care planning.
  • The service was easy to access. Staff managed discharge well and directed people to alternative care pathways if the service could not meet their needs.
  • The provider promoted equality and diversity in its day-to-day work and in providing opportunities for career progression. This included supporting clients to find volunteering opportunities after discharge.

7 to 17 December 2020

During an inspection looking at part of the service

This was a focused inspection to look at two of our key questions; how ‘safe’ and how ‘well led’ is the service?

Due to our concerns about how the service protected people from infectious diseases, such as COVID-19, we used our powers under section 31 of the Health and Social Care Act to take immediate enforcement action and keep people safe. We stopped the service from admitting any new clients and took further enforcement action relating to other breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Our overall rating of this location went down. We rated it as inadequate because:

  • The provider failed to ensure staff followed safe infection prevention and control procedures. Staff used working practices that did not meet national guidance to prevent the spread of COVID-19. Following our visit, we raised our concerns with the provider and asked them to take immediate action to ensure staff, volunteers and clients were safe.
  • The provider did not check whether staff had completed essential training to keep people safe from avoidable harm. They also did not check whether staff received regular supervisions and appraisals.
  • The provider did not always follow safe recruitment procedures and complete criminal record checks for staff who required them.
  • The service was not well-led. Leaders were not always visible in the day-to-day running of the service, which led to an accumulation of quality issues. For example, records relating to clients’ care and treatment were not kept-up to date.
  • Governance processes did not operate effectively to ensure the service ran smoothly.
  • Staff did not audit or evaluate the quality of care they provided. Fundamental issues within the service were not identified or rectified in a timely manner.
  • The provider did not always check directors were of good character and able to carry out their roles effectively. This included checks on the Nominated Individual of the service to ensure they were able to fulfil their statutory responsibilities.

However:

  • Staff responded to sudden deterioration in clients’ physical and mental health, working with external agencies to do this.
  • The culture of the service was person-centred, and staff and volunteers felt respected.
  • Since this inspection, the provider has taken urgent action to resolve immediate issues around infection prevention and control. Because of this the provider is now able to admit clients into the service again. We are monitoring the provider closely to ensure they also implement and sustain other improvements to ensure people receive care that is safe, and the service is better led.

31 July & 12 August 2019

During a routine inspection

Our rating of this service was good. We rated it as good because:

  • The service provided safe care. The clinical premises where clients were seen were safe and clean. The service had enough staff. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the clients and in line with national guidance about best practice.
  • The teams included or had access to the full range of specialists required to meet the needs of clients under their care. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and relevant services outside the organisation.
  • Staff treated clients with compassion and kindness and understood the individual needs of clients. They actively involved clients in decisions and care planning.
  • The service was easy to access. Staff planned and managed discharge well and had alternative pathways for people whose needs it could not meet.
  • The service was well led, and the governance processes ensured that its procedures ran smoothly.

However:

  • Although, clinical premises where clients received care were safe, clean, well equipped, well furnished, well maintained and fit for purpose, the chemicals and confidential waste in the outdoor shed were not appropriately stored to ensure restricted access.
  • Although, staff screened clients before admission and only admitted them if it was safe to do so, the service had no formalised policy to support staff with admissions into the service.
  • Although, the service had enough staff, who knew the clients and received basic training to keep them safe from avoidable harm, at the time of inspection, the out of hours on-call telephone service was manned by only two members of staff.
  • Some policies and procedures of the service were generic in nature and not specific to the client group. These were under review at the time of inspection.
  • Although, the service conducted clinical audits, these were not done regularly or consistently.

5 & 6 December 2016

During a routine inspection

We do not currently rate independent standalone substance misuse services.

We found the following areas of good practice:

  • Clients’ risk assessments were clear and updated regularly. There were robust processes to report, review and learn from incidents. All staff understood the safeguarding concerns surrounding the client group.
  • Clients’ care plans were holistic, detailed and recovery oriented. Clients had personalised goals in their care plans. The service had an aftercare programme that clients could attend for as long as they needed. The service had clear discharge planning protocols in place.
  • The service had enough staff to care for the number of clients and their level of need. Staff vacancy rates, turnover and sickness absence were all low. The service did not use bank or agency staff. Staff were regularly supervised and received an annual appraisal.
  • Management had clear oversight of the service. Staff attended a daily handover meeting where incidents, care planning and concerns were discussed. Staff took part in regular audits of the service to check that polices and clients’ care plans were up to date. The service took part in an auditing process by an external quality assurance scheme. The service was inspected by the external organisation in November 2016. This meant the service could see the areas where they were doing well and the areas needed to improve.
  • The service had clear infection control procedures to reduce the risk of infection in place. The service undertook regular health and safety checks. The service had an updated risk register and business continuity plan detailing how to continue operating the service in the event of a disruption.
  • Staff understood the needs of the client group they were supporting. Clients told us that staff treated them with dignity and respect.
  • The service created a magazine for and with the clients twice annually. It detailed what activities the service had been up to and information on the substance misuse sector.

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

  • Although staff had training in safeguarding vulnerable adults from abuse and understood child safeguarding procedures, the service had not provided training in safeguarding children to staff. Staff were scheduled to undertake child safeguarding training in January 2017.
  • Staff were very knowledgeable about the needs of clients with substance misuse problems but did not receive regular training in substance misuse to stay up to date with the developments in legislation and treatment.

25 September 2013

During an inspection looking at part of the service

At our previous inspection on 16 April 2013 we found there was insufficient evidence that the appropriate processes and checks had been undertaken when recruiting staff. At this inspection we found that improvements had been made and there were effective recruitment and selection processes in place. The staff records we reviewed contained completed application forms. We saw that appropriate checks had been undertaken before people started work, including obtaining references from previous employers, undertaking disclosure and barring service checks and ensuring a person's eligibility to work in the UK.

16 April 2013

During a routine inspection

At the time of our inspection there were five people living at Freedom Recovery Centre. During our inspection the two people using the service who we spoke with told they felt well-looked after, supported by both staff and other people using the service and would recommend the service to others. One person said: 'This is my first time in rehab. As soon as I walked in, I wanted to walk out. But I spoke to (staff) and stayed. Now, I'm doing well. I'm working my programme.'

People's psychological, emotional and physical needs were assessed and care was planned and delivered in line with their individual care plans. People told us they felt safe and secure, physically and emotionally. One said, 'right now, in this house, I feel safe, like there are no threats'.

People described the staff as 'supportive' and as having the right attitude and skills. However, although there were policies and procedures in place to ensure robust recruitment and selection processes, for both salaried and volunteer staff, there was insufficient evidence that these procedures had been followed and applied fully and effectively. There were documents missing from staff files, and there was not sufficient evidence that all staff were checked and vetted prior to starting work at the service to ensure that all staff were appropriate to work with the vulnerable client group.

7 December 2012

During an inspection looking at part of the service

At our previous inspection on 2 May 2012 we found that the provider did not have appropriate arrangements in place to manage medicines.

At our inspection on 7 December 2012 we saw that there were appropriate arrangements in place for the safe handling, storage, administration and disposal of medications. Appropriate medicines policies and procedures had been put in place,. Systems were in place to safely store or dispose of medications, if this was required, and we saw evidence that staff had been trained in the safe handling of medication.

At our previous inspection on 2 May 2012 we also found the provider was not providing care in an environment that was suitably designed and adequately maintained.

At our visit on 7 December 2012 we saw that the provider had taken steps to meet Fire Safety Regulations, including maintaining regular checks on fire fighting equipment. Staff and service users had been provided with training in fire safety and health and safety. The kitchen flooring had been replaced and looked clean and hygienic. Broken tiling had been sealed. The kitchen had been deep cleaned, and was being maintained adequately; kitchen flooring had been replaced and broken tiling had been sealed.

2 May 2012

During a routine inspection

During our inspection we spoke with two of the people living at the service, and with their consent we looked through and discussed their care records with them.

We also talked to staff, clients using the drop-in services, and took into account comments made in service users' feedback forms and surveys.

People told us that they felt safe and secure at the Centre. One described it as their 'safehouse'.

People using the service understood the care and treatment choices available to them. They felt that they had been fully involved in their pre-admission assessment processes, and been given time to make the decision to enter the programme. They understood what was in their care plans and risk assessments, felt their wishes were central to their recovery plans and had been given copies of these plans.

A person using the service told us that describing the Centre as 'really good, is an understatement'.

People told us that their care managers, keyworkers and counsellors worked together well, and that all the staff had given them a lot of support and encouragement. Their comments about the daily activities, structured programme, access to and attitudes of staff and effectiveness of the recovery programme were all positive.