The Care Quality Commission
  • Residential substance misuse service

Archived: We Can Recover CIC

Overall: Inadequate read more about inspection ratings

45 Belmont Drive, Liverpool, L6 7UW 07956 155747

Provided and run by:
We Can Recover CIC

All Inspections

10 and 11 May 2023

During an inspection looking at part of the service

We Can Recover is a Community Interest Company located in West Liverpool. It has been registered with the Care Quality Commission since June 2021 to provide accommodation for persons who require treatment for substance misuse and treatment of disease, disorder or injury.

Following this inspection, we took urgent action and served a Notice of Decision which placed conditions on the service’s registration. The Notice of Decision prevented the provider from admitting any further clients to We Can Recover CIC. We were concerned about the unsafe care and treatment of the clients and the lack of good governance.

Due to the seriousness of the concerns identified in this report, the Care Quality Commission (CQC) was also due to issue other enforcement action and a Notice of Proposal to deregister the service.

However, on 12 June 2023 the CQC received an application from We Can Recover to deregister. We were informed that there were no clients at the service receiving a regulated activity.

Therefore, the Notice of Proposal to deregister the service and other enforcement action was not issued.

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

  • The service did not provide safe care. There was no monitoring of the cleaning processes and ligature risks were not mitigated.
  • There were gaps in the fire safety procedures and there was no observation policy. Medicine management was not safe.
  • The clinic room lacked the appropriate equipment and emergency medicines.
  • The service did not have enough staff with the correct skills, experience and training.
  • The service did not have access to the full range of specialists required to meet the needs of clients under their care. The doctor was not specialised in substance misuse detoxification. None of the managers or registered nurses had any experience of managing a substance misuse detoxification service. Managers failed to ensure that staff received training and supervision. Staff did not work well together as a multidisciplinary team or with any relevant services outside the organisation.
  • Staff did not assess and manage risk well or follow good practice with respect to safeguarding.
  • Staff did not develop holistic recovery plans that were informed by a comprehensive assessment. The admission process was not safe or robust. Staff did not engage in clinical audit to evaluate the quality of care they provided.
  • Staff lacked an understanding of the individual needs of clients. Incidents were not reported.
  • Staff did not plan and manage discharge well. Clients did not have discharge plans or unexpected exit from treatment plans. Clients near to discharge did not have information outlining the post-discharge process.
  • The service was not well led. The governance processes failed to ensure that its procedures ran smoothly. The service lacked an audit system. Managers were not aware of the failings of the service. There were large gaps in employment checks.

However:

  • There had been limited improvements, the clinical premises were well maintained with a repairs log in place. Sexual safety in terms of the environment had been rectified. There were now separate sleeping areas for males and females.
  • Staff treated clients with compassion and kindness. Clients reported the group therapy sessions to be beneficial and that the food was of good quality.

23 February 2023

During an inspection looking at part of the service

We Can Recover is a Community Interest Company located in West Liverpool. The service was registered to provide inpatient care and detoxification for up to 24 clients with non-opiate addictions such as alcohol or cocaine in their residential rehabilitation facility.

Due to the safety concerns identified on a previous inspection, the Care Quality Commission took immediate enforcement action to prevent this service providing care and treatment to clients until significant improvements had been made. Clients were not safe or at high risk of avoidable harm and the delivery of high quality care was not assured by the leadership, governance, or culture. The service did not have any clients on site due to the suspension of the service. At this inspection, the service could not evidence that all the improvements needed to ensure the safe care and treatment of clients had been made in time for the service to begin operating again on 01 March 2023.

I am placing the service into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will act in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

We rated it as inadequate because:

  • Clinic rooms were not fully equipped.
  • Although the service had contracted a named GP prescriber, their role and cover arrangements remained unclear.
  • Although the provider had recruited nursing staff, most lacked previous experience in substance misuse. Arrangements to cover gaps in staffing were not formalised and there was not a clear clinical escalation route for queries out of hours.
  • Staff were not provided with the skills needed to safely deliver care to clients in the service. Training records were updated to reflect staff had completed mandatory training, but there were still gaps in the nursing and support staff completion.
  • The admission process was unsafe, in that staff who screened client’s admission and risks were not trained to do so. The process for reviewing risk prior to admission was unclear.
  • Training records provided recorded only two of the four registered nurses had completed medicine administration training. The process around clinical oversight and supervision of registered nurses in medicine management remained unclear.
  • Leaders did not have the skills, knowledge, and experience to perform their roles. Managers, including the new clinical lead, did not have experience in delivering a medically managed detoxification service. Managers had acted on some issues identified in the suspension notice, but concerns around the safety of clients if the service began to operate remained.
  • Leaders had not implemented safe systems and processes to provide safe and good quality care to clients using the service. Information was not available to us during the inspection and requested information from the previous two inspections remained outstanding. Policies, protocols, and documentation did not accurately reflect how care was to be provided or how the service would operate should the suspension be lifted.

However:

  • The provider had purchased new equipment for the clinic room and had reviewed their arrangements for emergency medicines. The provider had reviewed their exclusion criteria to include those with complex health problems for whom they would not be able to provide care.
  • The service had provided Safeguarding Adults and Children’s’ training on how to recognise and report abuse, appropriate for their role, however there were still gaps in safeguarding children level two training. The provider had a safeguarding policy that reflected the service’s arrangements. Managers had completed all appropriate employment checks for every staff member who had commenced employment.
  • The service had revised the medicines administration policy and included additional guidance on as required medicines and a medicines risk assessment form. There were no clients on site due to the suspension of the service so we could not assess the process to safely prescribe, administer, record and store medicines.
  • The registered manager was not aware of or understood that the named GP under practicing privileges required a license as defined by the GMC. The named GP had not been vetted under Regulation 18 (schedule 3) fit and proper person employed, to ensure the named GP was a fit and proper person to be employed.

26 January 2023

During an inspection looking at part of the service

Due to the safety concerns identified on a previous inspection, the Care Quality Commission took immediate enforcement action to prevent this service providing care and treatment to clients until significant improvements had been made. At this inspection, the service could not evidence that all the improvements needed to ensure the safe care and treatment of clients had been made in time for the service to begin operating again on 1 February 2023.

We rated it as inadequate because:

  • Clinic rooms were not fully equipped, and staff did not check and maintain equipment in line with manufacturer guidance. There was no emergency equipment or emergency medicines available or risk assessment to assess which emergency medicines staff may or may not need in this service.
  • The service did not have enough experienced and accessible nursing and medical staff to deliver high quality, safe care. The service had contracted a GP prescriber, based in Birmingham, but it was not clear what their role involved other than remote prescribing. Three of the four recruited nurses had no previous substance misuse experience, including the newly appointed clinical lead. Arrangements to cover gaps in staffing were not formalised and there was not a clear clinical escalation route for queries out of hours.
  • Staff were not provided with the skills needed to safely deliver care to clients in the service. Training records were inaccurate, and the mandatory training programme was not comprehensive. Relevant training, indicated on the suspension notice, had not been arranged. Role specific training had not been completed by staff and the rationale for the allocation of training was not clear. Rotas did not ensure that staff working on all shifts had the necessary experience to safely care for clients. Details of training course content was not shared with the Care Quality Commission.
  • Staff that screened client’s admission and risks had not completed all of the role specific training required to fulfil their role. The service was unable to describe effective systems and processes to review risk prior to admission and it was unclear what the review process was and who this involved. The service had not confirmed that the GP prescriber would have access to client’s summary care records or current blood results when assessing admissions.
  • The service did not follow good practice with respect to safeguarding. Staff did not have Safeguarding Adults and Childrens’ training on how to recognise and report abuse, appropriate for their role. This information was specified in the suspension notice that was issued following the first inspection. The provider did not have a safeguarding policy that reflected the service or best practice; it was dated 2013 and for an NHS trust. Managers did not complete all appropriate employment checks for every staff member working in the service.
  • The service had not established systems and processes to safely prescribe, administer, record and store medicines. Staff who were to administer medicines were not all suitably qualified and competent to administer medicines safely. The policy which support worker medicines training was based upon, was contradictory and of poor quality. Processes surrounding medicines administration records, clinical supervision, medicines disposal and medicines training were not clear.
  • Leaders did not have the skills, knowledge and experience to perform their roles. Managers, including the new clinical lead, did not had experience in delivering a medically managed detoxification service. Managers had not acted on all issues identified in the suspension notice.
  • Leaders had not implemented safe systems and processes to provide safe and good quality care to clients using the service. Information returned was not timely and accurate. Managers struggled to return basic information that was associated with the day to day running of the service. Policies, protocols and documentation did not accurately reflect how care was to be provided or how the service was run.

However:

  • The provider had created organisational visions and values that were included in the newly implemented staff induction.
  • The service had implemented improved paperwork to ensure clients were given all their first day doses in their detox regimen.

Letter from the Chief Inspector Hospitals

I am placing the service into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

29 November 2022, 30 November 2022

During an inspection looking at part of the service

Due to the safety issues identified on this inspection the Care Quality Commission took immediate enforcement action to suspend the provider’s registration. This meant that the service was not allowed to provide care and treatment to clients until significant improvements had been made. A final version of this report, which we will publish in due course, will include full information about our regulatory response to the concerns we have described.

We issued a Notice of Decision to suspend registration because we were not assured that staff had the qualifications, competence, skills and experience to care for clients safely. Support workers, who were caring for people in alcohol withdrawal were not competent, skilled or experienced in either the assessment and monitoring of withdrawal symptoms or in responding to potentially very serious physical health side effects. Two clients required admission to emergency acute care following alcohol withdrawal related seizures. Staff were not trained in essential skills to recognise and respond to people’s health deteriorating due to alcohol withdrawal or and had not received other mandatory training.

We were not assured that staff were appropriately qualified. The service did not provide registered nurse staffing 24 hours a day, seven days a week, in line with their Care Quality Commission registration. Agency nurses, when used, did not have the required skills and experience to provide care. There was no clinical leadership in the management team when we inspected on 29 November 2022. We found that in seven of nine staff employment files we reviewed there were no readily available DBS checks or outcomes recorded. We could not find the required two employment references for registered nurses.

We were not assured that there was effective medicines management to ensure clients received safe care and treatment. We found systems were not robust to ensure safe management of medicines and clients were exposed to serious risk of harm. Staff who administered medicines, were not all suitably qualified and competent to administer medicines safely. Staff did not have the formal training to use formal assessment tools to assess the nature and severity of alcohol misuse. Assessment tools to determine the severity of withdrawal symptoms were not always effectively completed for clients who were detoxifying from alcohol. This potentially increases the risk of adverse physical effects from alcohol detoxification, such as seizures. Staff had failed to obtain clinical guidance from a suitable person with the necessary skills and competence when a client was not available for all of their first day detoxification doses. We found that clients did not always receive their full detoxification regime. There were no emergency medicines available for staff to use in an emergency such as a seizure, emergency medicine could stop the seizures or no appropriate risk assessment to assess which emergency medicines staff may or may not need in this service.

We rated it as inadequate because:

  • The service did not provide safe care. The clinical premises where clients were seen were not safe and clean. Managers had not identified all environmental, ligature and fire risks or taken action to mitigate them. Staff did not clean the environment in line with infection prevention and control procedures and follow universal masking procedures during a covid outbreak.
  • Premises were not suitable for the client group and managers had not implemented processes that reduced risk. The service provided mixed sex accommodation and did not have enough bathrooms that clients could safely access. Clients were allocated to bedrooms without consideration of sexual safety or detoxification side effect risks.
  • Maintenance issues were not acted on and resolved quickly. The premises refurbishment had not been fully completed before clients were admitted. There was no oversight of maintenance jobs that needed completed.
  • Clinic rooms were not fully equipped, and staff did not check and maintain the equipment they had. There were no emergency equipment or emergency medicines available for staff to use in an emergency such as a seizure; emergency medicine could stop the seizures. There was no appropriate risk assessment to assess which emergency medicines staff may or may not need in this service.
  • Managers had not ensured that staff had Basic or Immediate Life Support training, or an emergency first aid trained member of staff always on shift.
  • The service did not have enough nursing and medical staff working in the service to keep clients safe 24 hours a day, seven days a week. There was no clinical leadership and staff could not access any medical input when we inspected on the first day. The service had only one part time nurse employed that physically worked on the premises on a part time basis. The registered manager had also contracted an independent nurse prescriber to remotely assess new admissions in evening prior to admissions.
  • Managers did not ensure that all staff, including agency staff, had a full induction and understood the service before starting their shift. Agency nurses we spoke with had no prior experience in detoxification or substance misuse services.
  • Staff did not receive basic training to keep people safe from avoidable harm. Although some staff had completed statutory training, none of the staff had completed nine of the eleven training courses required to deliver client care. The other two courses had poor training compliance rates and the service. The mandatory training programme was not comprehensive and did not meet the needs of clients and staff. Managers did not provide staff training in the Mental Capacity Act, Clinical Risk Assessment, Medicines Management training or the appropriate level of Safeguarding training.
  • Staff did not complete effective risk assessments for each client prior to admission and on arrival. The service did not use a recognised tool in line with best practice, risks were not categorised appropriately, and risk management plans were not created. None of the 11 risk assessments we viewed were signed by a doctor, nurse or manager. Staff did not use tools to assess and screen alcohol harm and dependence or when assessing risk or access to a full GP summary before commencing detox regimes. The service admitted clients even when it was not safe to do so.
  • Staff did not follow good practice with respect to safeguarding. Staff did not have training on how to recognise and report abuse and the provider did not act in accordance with its own policy. Staff did not inform the local authority of all safeguarding incidents. Managers did not complete all appropriate employment checks for every staff member working in the service.
  • The service did not fully use systems and processes to safely prescribe, administer, record and store medicines. Staff did not regularly review the effects of medicines on each client's mental and physical health. Staff who administered medicines were not all suitably qualified and competent to administer medicines safely. Staff did not always record alcohol assessment scales regularly and clients did not always receive all medicines over the course of their prescribed detoxification.
  • The service did not manage client safety incidents well. Most staff did not recognise incidents and report them appropriately. Managers did not investigate incidents or share lessons learned with the whole team. When things went wrong, managers did not apologise and give clients honest information and suitable support.
  • Leaders did not have the skills, knowledge and experience to perform their roles. None of the management team had experience in delivering a medically managed detoxification service. None of the managers had clinical experience and managers had not made suitable arrangements to ensure there was clinical leadership and input into the service before admitting clients.
  • Organisational data including staff and client records were not stored securely. Care records and staffing data were stored on google shared drive which is not compliant with all data protection regulations.
  • Managers had not created a safe and open culture where staff felt supported and valued. Managers did not provide inductions, supervision or regular team meetings. The provider did not have any vision and values that were shared with their staff or applied to the work of their team.
  • Leaders had not implemented safe systems and processes to provide safe and good quality care to clients using for the service. Managers did not have access to information to support them with their management role. Managers struggled to locate basic information that was associated with the day to day running of the service. Information was not timely or accurate; it did not identify areas for improvement. We reviewed training and recruitment systems and processes, policies and provider documentation including incident reporting systems that were not accurate, complete or updated. None of the policies we reviewed reflected the care being provided or how the service was run.

However:

  • Clients described most staff as nice, lovely or good.
  • Clients said that the food provided was of excellent quality and that the service met specialist dietary requirements.
  • Clients could contact staff on walkie talkies if they needed assistance during the first few days of detoxification.
  • Clients and staff said that most managers were present in the service.
  • Support staff updated client progress notes each shift.