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Inspection carried out on 04 April 2018

During an inspection to make sure that the improvements required had been made

We do not currently rate independent standalone substance misuse services. Our last comprehensive inspection of Broadway Lodge was in April 2016. At that inspection, we issued five requirement notices. Issuing a requirement notice notifies a provider that we consider they are in breach of legal requirements and must take steps to improve care standards. On 4 April 2018 we undertook an unannounced, focused inspection to see whether the provider had made the required improvements.

  • At the last inspection in 2016 we asked the provider to ensure clients admitted for detoxification from opiates have individual care plans and risk assessments to ensure staff can appropriately manage risks. In April 2018, we found clients had care plans and risk assessments in place including ones that related to detoxification from opiates. Staff involved clients in developing their care plans and risk management plans. Further work was needed to ensure risk assessments addressed previous risks for each client such as where they had previously had seizures.

  • At the last inspection in 2016 we said the provider must ensure staff reviewed and thoroughly investigated incidents and acted to prevent incidents re-occurring. At this inspection we found the management team reviewed incidents and told staff about any lessons learnt from them. However, further work was needed to collate all the incidents so that themes and trends could be found. The staff team had completed environmental risk assessments that were up to date.

  • At the last inspection in 2016 we said the provider must ensure policies and procedures allow anyone to raise concerns about their care and treatment or the care and treatment of people they represent.

  • At the last inspection in 2016 we said the provider must ensure staff receive regular appraisals and any training, learning and development needs should be identified and supported.

  • At the last inspection in 2016 we said the provider must ensure records are accessible to authorised people to deliver clients care and treatment in a way that meets their needs and keeps them safe.

Inspection carried out on 5 April to 7 April 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:

  • 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 carried out on 21 June 2013

During an inspection to make sure that the improvements required had been made

We carried out this inspection to follow up a compliance action made at an inspection which took place on 11 February 2013.

During this inspection we did not speak with people who used the service. We spoke with three staff members about the procedures that had been put in place to protect people from risks associated with medicines.

We found the receipt, storage and administration of medication was managed safely. This meant the systems in place protected people from the risks associated with medicines.

Staff spoken with told us they had made changes to the way medication was administered. This included a separate room in the main house which meant people were seen individually when medication was administered.

Inspection carried out on 5, 11 February 2013

During a routine inspection

Broadway Lodge provides different stages of the 12 step treatment programme in separate buildings therefore we spoke to four patients who used the detoxification programme; five patients who used the primary care and two who used the secondary care programme.

Patients we met with told us they were given full and detailed information about the programme they would undertake, before they were admitted. We saw in the care files that written consent had been sought from the patients in a variety of areas of service delivery. Patients who spoke with us confirmed this had occurred.

Patients spoken with told us that they felt their needs had been fully assessed and that staff understood them as an individual. There was an expectation patients would complete therapeutic duties and contribute to the running of the home. They told us “this develops a sense of responsibility between us.”

Patients we spoke with told us they had confidence in the quality of the staff knowledge, skills and experience. They told us “the staff are excellent” and “they are very skilled in the observation of people, they know when something isn’t right and act on it.” The patients we spoke with were able to articulate their own needs and comments and were confident about complaining.

We saw that the processes for record keeping of non stock medication were inadequate. We have made a compliance action requiring the provider to take appropriate action to address this area of non compliance.

Inspection carried out on 12 September 2011

During a routine inspection

The clients we met were positive in their views of the treatment they are getting and how they are supported by the staff, examples of the comments made to us included, "it's a very welcoming place ,very welcoming and friendly everyone is very considerate" and “they have brilliant staff, out of everywhere that I've been it's the only place that ever worked for me", and "it's brilliant here ,they give you the tools and they tell you what you

should do ,I can’t fault the place the strength of this place is that they treat clients like human beings".

Clients told us that they feel that Broadway Lodge is a supportive place to stay. One person told us, "the support staff are good and they are really strong on boundaries here".

Clients also told us they are well supported by the staff to regain independence in their daily lives when they leave Broadway Lodge after completing treatment there. Clients said staff spend time with them and listen to them and talking to them in a way that is respectful and sensitive to their needs. As one client explained, "it's the empathy between

staff and clients here, everyone is listened to".

Reports under our old system of regulation (including those from before CQC was created)