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Archived: Cranstoun - Trelawn House

Inspection Summary


Overall summary & rating

Updated 14 July 2017

We do not currently rate independent standalone substance misuse services.

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

  • At the last inspection in September 2016, we identified that staff were not always completing client’s risk information appropriately or in enough detail. During this inspection, we found that the quality of risk assessments and management plans was inconsistent.

  • Clients’ risk assessments and care plans did not always identify risks associated with clients’ physical health. Care plans did not always specify how best to support clients with complex physical health needs.

  • After the service had been inspected in September 2016, the provider had undertaken a service risk assessment in response to our findings. However, the provider had not reviewed the service’s risk assessment since December 2016.

  • The provider had identified a range of formal audits that needed to be undertaken to ensure that the quality and safety of the service was monitored. The provider had not fully implemented the schedule of audits.

  • The service was not routinely using early unplanned exit plans for clients. Clients were not being given information as to how to minimise the risk of overdose should they decide to leave treatment early. Clients who have recently undergone alcohol or drug detoxification are at increased risk of overdose.

  • Staff were not having regular documented supervision. This meant that staff did not have regular monthly one to one support in line with the provider’s supervision policy.

  • Staff were not routinely monitoring the temperatures in the medicines and food fridges. Staff were not undertaking regular fire drills, routine checks of fire equipment and checks on emergency lighting.

  • At the last inspection in September 2016, we found that there were a number of medicine errors in the service that had not been reported or acted upon. During this inspection, we found that there had been 17 medicine errors reported between February 2017 and May 2017. We found that staff had not identified two medicines errors.

However, the service had made some improvements since our last inspection in September 2016. We found the following areas of good practice:

  • During the inspection undertaken in September 2016, we found that medicines management was unsafe. Multiple medicine errors had occurred. The service had not assessed staff as competent to dispense medicines. During this inspection, we found that the provider had trained staff in medicines management.

  • At the last inspection in September 2016, we noted that staff had a poor understanding of safeguarding adults and children. During this inspection, we found that the provider had trained staff in safeguarding adults and young people. All staff knew how to make safeguarding referrals.

  • At the last inspection in September 2016, we found there were low completion rates of mandatory training. During this inspection, we found that the completion rates of mandatory training had improved.

  • At the inspection in September 2016, we asked the provider to improve their pre-employment checks. The provider had improved their recruitment processes and there were now procedures in place to ensure that pre-employment checks were completed for new staff.

  • When the service was inspected in September 2016, we identified that the provider’s governance processes did not ensure the safety and quality of the service. Since that inspection, the provider had reviewed their governance processes. The new processes were not fully embedded at the time of this most recent inspection, though work had begun on this. The provider had begun the process of reviewing their policies to ensure that they were in line with best practice guidance.

  • At the last inspection in September 2016, we found that the service was not reporting all incidents that occurred in the service. During this inspection, we found that the service had acted on the findings of the September 2016 inspection. The service was reporting and reviewing all incidents that happened in the service.

  • When we inspected the service in September 2016, we identified that clients’ care plans were not specific or measurable. During this inspection, we found that the service was introducing new care planning documents. The new plans allowed clients to identify specific measurable goals. The process was not fully embedded at the time of this inspection.

  • At the last inspection we found that the staff working in the service did not understand the principles of the Mental Capacity Act. During this inspection, we found that the service had acted on the findings of the September 2016 inspection, and had provided staff with training in the Mental Capacity Act.

  • When the service was inspected in September 2016, we found that the service was not clean. During this inspection, we found there was regular cleaning of the service. Staff were monitoring the cleanliness of the service.

  • At the last inspection in September 2016, we found that food was being stored incorrectly in the fridge. During this recent inspection, we found that the service was now storing food items on the correct shelves in the fridge.
Inspection areas

Safe

Updated 14 July 2017

We do not currently rate standalone substance misuse services.

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

  • When the service was inspected in September 2016, we identified that staff were not always completing client risk information appropriately or in enough detail. Some clients did not have risk management plans. During this inspection, we found that all clients had risk management plans. However, the quality of risk assessments and management plans was inconsistent. Staff completing the assessments did not always identify and plan for physical health risks.

  • Staff did not undertake regular checks on fire and emergency lighting equipment.

  • Staff were not always monitoring the room and fridge temperatures.

  • At the last inspection in September 2016, we found that staff had not maintained accurate medicines administration records for clients. During this inspection, we found that medicines administration records for two clients were incomplete and this had not been identified by staff. Seventeen medicines incidents had occurred since February 2017 in the service.

However, we found the following areas of good practice:

  • At the last inspection in September 2016, we found that staff had not been trained in medicines management. During this inspection, we found that the provider had trained staff in medicines management. Staff had been assessed as competent to support clients whilst they took their medication.

  • At the last inspection in September 2016, we noted that staff had a poor understanding of safeguarding procedures. During this inspection, we found that the provider had trained staff in safeguarding adults and young people. Staff now discussed safeguarding concerns as part of their daily meetings. All staff knew how to make safeguarding referrals.

  • At the last inspection in September 2016, we noted that there were low completion rates of mandatory training. During this inspection, we found that the completion rates of mandatory training had improved. Staff had the core skills and knowledge necessary for their role.

  • When the service was inspected in September 2016, we found that the service was not reporting all incidents that occurred in the service. During this recent inspection, we noted that there had been improvements, the service was reporting and reviewing all incidents that happened in the service.

  • At the last inspection in September 2016, we found that the provider was not undertaking satisfactory pre-employment checks. During this inspection, we found that the provider had reviewed their recruitment processes and there were procedures in place to ensure that pre-employment checks were undertaken on all new employees.

  • When the service was inspected in September 2016, we found that the service was not clean. During this inspection, we found that there was regular cleaning of the service. Staff were monitoring the cleanliness of the service.

  • When the service was inspected in September 2016, we found that food was being stored incorrectly in the fridge. During this recent inspection, we found that the service had improved the storage of food in the fridge.

Effective

Updated 14 July 2017

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

  • When we inspected the service in September 2016, we found that staff were not having regular documented supervision. During the inspection in May 2017, we found that the service had not made improvements. Staff were still not having regular documented supervision.

  • When we inspected the service in September 2016, we identified that clients’ care plans were not specific or measurable. They did not reflect clients’ involvement and preferences. Staff did not always give clients a copy of their care plans. During this inspection, we found that the service was introducing new care planning documents, which allowed clients to identify specific goals that could be measured. The new care planning documents allowed the client to be fully involved in the care planning process. The provider had not fully embedded the process at the time of this inspection.

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

  • The service had acted on the findings of the September 2016 inspection, and had provided staff with training in the Mental Capacity Act.

Caring

Updated 14 July 2017

We do not currently rate standalone substance misuse services.

We found the following areas of good practice:

  • Staff had a good understanding of clients’ needs. We observed that staff treated clients with dignity and respect.

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

  • It was not always clear from the files whether clients had been offered of a copy of their care plans.

Responsive

Updated 14 July 2017

We do not currently rate standalone substance misuse services.

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

  • Not all clients had an unplanned early exit plan. It was not always clear what clients should do if they left treatment early. Clients who have recently undergone detoxification are at high risk of overdose.

Well-led

Updated 14 July 2017

We do not currently rate standalone substance misuse services.

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

  • When the service was inspected in September 2016, we found that the service had not undertaken a service risk assessment. During this inspection, the provider had undertaken a service risk assessment but had not reviewed it since December 2016. The provider could not be assured that risks were being managed in a timely manner.

  • The provider had identified a range of formal audits that needed to be undertaken to ensure that the quality and safety of the service was monitored. However, at the time of the inspection in May 2016, very few of these audits had been completed.

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

  • The inspection in September 2016 identified that the provider’s governance systems for the service were not effective. During this inspection, we found that the provider had reviewed their governance processes. Managers reviewed governance at a local level. The senior management team met to review incidents, trends, and issues relating to the service. The processes were not fully embedded at the time of this most recent inspection.

  • When the service was inspected in September 2016, we found that the provider had not reviewed their policies on a regular basis. The policies did not reflect best practice guidance. During this inspection, we found that the provider had begun the process of reviewing their policies to ensure that they were in line with best practice guidance.
Checks on specific services

Substance misuse services

Updated 14 July 2017

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