• Residential substance misuse service

Archived: Chelmsford

Overall: Inadequate read more about inspection ratings

45 Broomfield Road, Chelmsford, Essex, CM1 1SY (01245) 491276

Provided and run by:
PCP (Luton) Limited

Latest inspection summary

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Background to this inspection

Updated 11 April 2022

PCP Chelmsford is an independent substance misuse service for clients with an alcohol or substance addiction, providing treatment for up to 18 adults under the age of 65. The location was registered with the CQC in July 2011. The service has a registered manager and a nominated individual. PCP (Luton) Limited is the registered provider.

The service is registered for:

  • Treatment of disease, disorder or injury
  • Accommodation for persons who require treatment for substance misuse

Treatments offered at PCP Chelmsford include medically assisted withdrawal and detoxification programmes and therapy programmes, for clients addicted to alcohol or substances.

The location offers one to one counselling and a range of therapy groups, including medication, the 12-step programme, art therapy, meditation, euphoric recall, relapse assessment and prevention, and harm minimisation. Accommodation for the detoxification programme is not provided on site, but at a nearby house separately registered with CQC. PCP Chelmsford consists of a day treatment centre, where all clients go daily to receive treatment and therapy, and four treatment houses where clients live and spend their evenings during treatment. One of these houses is used for clients requiring detoxification and is staffed 24 hours, seven days a week. We inspected the New Writtle Street location as part of this inspection. There is a separate report for that location.

We undertook a focussed inspection of this service as a follow up to our inspection in April 2021 where we found significant concerns. Following this inspection, we rated the service as inadequate, and issued an urgent section 31 notice of decision to place conditions on the service’s registration. These conditions stated:

1. The Registered Provider must devise, review and assess the effectiveness of the system(s), process(es) for the service in particular to but not limited to:

a) Records keeping of services users assessed and admitted to the service;

b) Investigations and review of incident reporting;

c) Investigation and review of complaints management;

d) Review of equipment;

e) Review of staff training appropriate to their role.

2. The Registered Provider must not admit any service users who require a new course of detoxification treatment from addictive substances without the prior written agreement of the Care Quality Commission.

3. The Registered Provider must devise a process and undertake a review of current service users admitted for detoxification of addictive substances with accurate clinical risk assessment and care planning, in particular ensure that the level of service user’ needs are individualised, recorded and acted upon. This must include but not limited to

a) prescribed medication review;

b) a clear process for documentation that inform staff of the current care planning where applicable, of all service users this includes details of any changes to service users’ individualised needs are clearly recorded and are easily accessible to relevant staff and acted upon.

4. The Registered Provider must provide the Care Quality Commission with a report setting out the actions taken or to be taken in relation to conditions above by 23 April 2021 and every Friday after that. The report must also include the following:

a) details of the system(s) and processes that are implemented to comply with the conditions,

b) details and confirmation of action taken to ensure the system(s) are being audited and monitored to improve the quality and safety of services,

c) Details and confirmation of action taken to ensure incidents and complaints are recorded, investigated and lessons learned shared with staff.

We also told the service action they must take:

  • The service must ensure that it follows the government’s guidelines on Covid-19: infection prevention and control. Regulation 12(1)
  • The service must ensure that staff follow the services Covid-19 risk management plan to protect clients and staff.
  • The service must ensure that they manage medication safely and follow national guidance. Regulation 12(1)
  • The service must ensure that it follows the guidelines which are set out in the drug misuse and dependence – UK guidelines on clinical Management (also known as the Orange book) when providing medical detoxification to clients. Regulation 12(1)
  • The service must ensure staff regularly check all medical equipment to ensure it is working correctly. Regulation 12(1)
  • The service must ensure that it reports and investigates incidents in line with their policy. Regulation 17(1)
  • The service must ensure that it implements a robust governance system to monitor the effectiveness of the service. Regulation 17(1)
  • The service must ensure that it responds to and investigates complaints in line with duty of candour. Regulation 16(1)
  • The service must ensure it has a system in place to record and monitor risks to the service. Regulation 17(1)

Following our inspection of this service the provider took the decision to close the service and deregister. All clients were either discharged or transferred to one of the provider’s other services.

What people who use the service say

We spoke with three clients who all told us that the staff were kind caring and compassionate. They felt well supported and told us that staff were always available for one to one time if they required. Clients felt that the treatment programme was appropriate and met their needs.

Overall inspection

Inadequate

Updated 11 April 2022

PCP Chelmsford is an independent substance misuse service for clients with an alcohol or substance addiction, providing treatment for up to 18 adults under the age of 65. The location was registered with the CQC in July 2011. The service has a registered manager and a nominated individual. PCP (Luton) Limited is the registered provider.

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

  • Staff working patterns were unsafe. In one week, the registered nurse worked 69 hours which put them and the clients at risk of avoidable harm.
  • Staff did not follow the provider’s policy for observing clients on enhanced observations. Staff did not always update risk assessments.
  • Staff did not complete audits appropriately. Staff did not make necessary improvements following the results of audits. Senior leaders did not ensure an action plan for improvement was implemented or actioned.
  • Staff did not always report safeguarding concerns. Senior leaders did not know what incidents should be reported or referred as a safeguarding concern.
  • Leaders did not always demonstrate the skills, knowledge and experience to perform their roles. Senior leaders did not know what incidents should be reported or referred as a safeguarding concern.

However:

  • 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.
  • Staff treated clients with compassion and kindness and understood the individual needs of clients. They actively involved clients in decisions and care planning.