All inspections: Passmores House - Care Quality Commission

We rated Passmores House as good because:

The ward environment was safe, clean, well equipped, well furnished, well maintained and fit for purpose. The service had appropriate arrangements in place for managing medicines and controlled drugs. The service had enough nursing and medical staff, who knew the clients and thoroughly assessed their risks throughout their admission. Staff reported incidents in line with the providers policy and knew how to protect clients from abuse, by working with various organisations. All staff received an induction, regular supervision and could access specialist training.
Staff, including an on-site GP assessed the physical and mental health of all clients on admission, created care plans and kept them updated during admission. Clients said this was supportive to their treatment. The doctor wrote a discharge summary for each client when they completed detoxification and when they completed rehabilitation to ensure continuity of treatment. Staff managed the waiting list and potential clients could be prioritised if their risk was high.
Staff followed National Institute of Health and Care Excellence and Department of Health guidance for treatment by encouraging their clients to live healthier lives and offering a range of supportive therapies to aid recovery.
Staff treated clients and family members with compassion and kindness, and supported clients to make decisions on their care for themselves. Staff used assessment tools which considered all principles of the Mental Capacity Act. Staff supported clients to access services in the local community such as legal advice and housing support. The service had received many compliments and treated concerns and complaints seriously, investigated them and learned lessons from the results.
Staff allocated bedrooms based on a holistic assessment of the client’s physical health needs, vulnerabilities and gender. The service offered a range of food choices to meet people’s needs.
Staff felt respected and were aware of organisational vision and strategy. Managers and staff monitored the performance of the service and participated in national benchmarking projects. Senior managers engaged with staff, clients, and family members on how to improve the service.

We do not currently rate independent standalone substance misuse services.

We found the following areas of good practice:

The service had appropriate numbers of staff on all shifts. Duty rotas showed the service covered all shifts with the appropriate number of staff with the right skills, training, and experience to ensure that clients were safe. Staff compliance with mandatory training was 97%, Staff received regular supervision and compliance was 100%. We observed staff attitudes and behaviours when interacting with clients. Staff treated clients with dignity, compassion, and respect. We spoke to five clients who all told us that the staff were very kind and caring.
Clients received a comprehensive and timely assessment upon admission. Staff used information gathered during the assessment to complete an initial care plan and determine the detox regime for the client. Staff undertook a risk assessment of every client upon admission; these were detailed and included crisis plans and emergency discharge plans for when clients leave treatment. Clients’ records contained up to date, holistic, recovery orientated care plans. Each client had personalised care plans that included a plan for recovery and discharge. Clients had signed their care plans and staff had given them a copy.
There were good medicines management procedures in place. Medication was stored appropriately, in locked cupboards within the clinic room and the nurse in charge held the keys. Clients had good access to physical healthcare. The GP was available Monday to Thursday, to monitor clients’ physical healthcare needs and a psychiatrist was available Monday to Friday. The service was able to refer to local physical health specialist teams, where necessary. The service offered electrocardiograms to clients upon admission to check for cardiac anomalies caused by cocaine and alcohol use.
The service had a full range of rooms and equipment to support treatment and care. There were group rooms for therapeutic activities. Clients had access to smaller rooms for one to one sessions, quiet time, or to meet visitors. Clients had access to activities seven days a week. These included access to a personal trainer who attended once a week, swimming and therapeutic group activities.
The provider had systems in place to monitor mandatory training and supervision. Managers kept records of when staff had completed mandatory training and received supervision. These were all up to date. Managers shared lessons learned from incidents and complaints. We reviewed the minutes of team meetings, saw that lessons learned was a standard agenda item, and staff discussed these regularly.

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

There were ligature points throughout the service (a ligature anchor point is anything which a person could use to attach a cord, rope or other material for the purpose of hanging or strangulation). The provider had completed a ligature risk assessment; however this did not identify all potential ligature anchor points. We highlighted this to the manager who took action to get this rectified.
Staff had not completed risk assessments for female clients in the mixed sex corridor. The service was able to provide copies of risk assessments they had implemented following the inspection. However, these were generic risk assessments and were not individualised to the client.
Staff had not documented assessments for clients who they felt had impaired capacity. The service did not have procedures in place to monitor compliance with the Mental Capacity Act.

We do not currently rate independent standalone substance misuse services.

We found the following areas of good practice:

The clinical team carefully considered and planned the admission process before the client entered Passmores House, working with community services to gather information. There was evidence of detailed admission and risk assessment before and on admission. A doctor undertook comprehensive medical assessments with the client the day they arrived.
There was a qualified nurse present daily to assist clients in managing symptoms of withdrawal from substances or alcohol, and staff received adequate training to manage these safely. The clients had consistent access to a prescribing doctor Monday to Friday. There was also an out of hours on call system for medical support.
The provider told us that the doctor prescribed medication as described by Department of Health guidance, drug misuse and dependence: UK guidelines on clinical management (2007) for alcohol and opiate detox. A prescribing policy was in place that followed national guidance. The provider used nationally recognised treatment outcomes profiles (TOPS), opiate withdrawal scales and severity of alcohol dependence questionnaire (SADQ) to measure outcomes of people’s treatment and to monitor detoxification whilst in the residential setting.
Care plans were recovery focussed and demonstrated close working with the client. Staff treated clients with kindness and respect. We observed positive interactions that were meaningful and supportive. Staff understood individual client’s needs.
The service had a clear policy around unplanned exit from services should a client decide to leave unexpectedly. All clinical records reviewed had a documented plan, specific to the client, in case of such an eventuality.
Staff understood the principles of safeguarding and how and when to report a suspected safeguarding concern. Safeguarding children was an integral part of clients care plans.
The clinic room was well maintained and stocked. Staff carried out regular audit to ensure equipment was fit for purpose. There were effective medication management systems relating to transport, storage, dispensing and medicine reconciliation processes. Medicine reconciliation is a process where the provider checks with the GP that medications received by the client are still valid and against a current prescription. Staff had access to a fully equipped emergency bag, which contained resuscitation equipment and emergency drugs, which staff checked regularly.
People with disabilities were able to access the service, there was an adapted bedroom and most facilities where on the ground floor. There was no lift in the building to get to upper levels but this did not restrict people with disabilities accessing services.

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

The provider did not complete risk assessments for staff with previous convictions. Whilst a conviction would not necessarily exclude someone from working in a substance misuse service, a risk assessment would identify and mitigate any risks to ensure that people using the service were kept safe.
The service did not have a clear, transparent system for learning when things went wrong.
Mandatory training is training the provider had said all staff must attend. Attendance rates were variable. The provider target was 90% of staff to attend mandatory training sessions. The lowest attendance was 42% and the highest 100%.
Staff received supervision but not consistently and not in line with their own policy.

We spoke with eight people who used the service. We also spoke with the area operational manager, interim service manager, nurse manager and two members of staff. We looked at four people's care records, staff rota's, therapy timetables, policies and procedures, audits and medication records.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

When we arrived at the service we were greeted by a member of staff and introduced to the interim service manager.

The security and leave arrangements in place form part of the contract for people who use the service

One person told us they felt safe at the service and that they had spoken when they felt unwell and the staff had supported and reassured them. Another person said. 'I feel safe here, a beautiful place, enjoy the garden and the staff have helped me understand my problems.'

We reviewed staffing records regarding the Mental Capacity Act (MCA) 2005 in relation to Deprivation of Liberty Safeguards (DoL'S) and saw this training was up to date. The CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The interim service manager in day to day management of the service was able to demonstrate a knowledge and understanding of the MCA and DoL'S. There were no DoL'S in place.

Is the service effective?

People's care records showed that care and treatment was planned and delivered in a way that was intended to support people's recovery and welfare. The service had a range of therapies available including complimentary therapies. The service also provided counselling and relapse prevention, of which all people we spoke with had found helpful. The care plans were indexed for ease of reading and finding information. People who used the service worked with the cook and catering staff to devise menu plans. There was water and fresh fruit available at all times People could engage with training to achieve the basic food hygiene certificate, this boosted confidence and was an award the person could leave the service with. One person showed us the garden where they were growing vegetables. There were arrangements in place for the staff to work with other organisations to support people to follow their life-style choices and provide care.

Is the service caring?

We saw that the staff interacted with people who used the service in a caring, respectful and professional manner. One person said. 'The staff are lovely because they always listen.'

Is the service responsive?

The service had a structured programme for all people who used the service. The service responded to people individually having listened to their concerns and taken account of assessments and progress, through an individualised therapy programme. This was discussed with the placement care manager and person who used the service to identify the length of stay at the service and plan achievable outcomes. Another person told us. 'There are too many bank or agency staff, so I do not want to talk with them much as they do not know me.'

Two people told us that they knew how to make a complaint if they were unhappy.

Is the service well-led?

The service employed a multi-disciplinary team of staff to provide therapy and support to people's assessed needs. The service had identified its reliance upon bank staff and had recruited three new members of staff in the previous month.

The service had addressed the issues of non-compliance of our previous inspection with a detailed action plan which had been implemented. At this inspection we did find a new matter of non-compliance. The service took immediate steps at the time to resolve the issue.

Risk assessments were often sparse in their level of detail. Care and treatment was not planned in a way that was intended to ensure people's safety and welfare.

The manager had worked with other agencies to ensure appropriate care had taken place.

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place for the management, administration and recording of medicines.

We found that the skirting boards, doors and walls were scuffed and marked and that the carpet required vacuuming. There was not an appropriate standard of cleanliness and hygiene in the premises.

There was a leaking radiator on the first floor outside people's bedrooms. There was a towel underneath the radiator to soak up the liquid. In the accident book, we saw that a person had slipped on leaking radiator fluid three months before our inspection. We were informed by the provider that this accident related to a different radiator. The provider had not taken steps to provide care in an environment that was suitably designed and adequately maintained.

During our inspection of this service on 17 July 2012 we identified that people's care plans did not show sufficient information for the people who used the service to understand their care or treatment. We found that people's views or experiences were not always taken into account in the way the service was provided and delivered in relation to their care. We had also found that care was not planned and delivered in a way that ensured people's safety and welfare. This was because there was no management plan attached to specific risks that had been identified.

We carried out a further inspection on 29 January 2013. This was to check that the provider had made the improvements detailed in the plan submitted to us following the report of our visit in July 2012. We looked at six care plans and were satisfied that these were personalised and that all relevant risk assessments had been completed.

We spoke with three out of the 16 people that live at Passmores House. We also spoke with one relative of a person who used the service.

All of the feedback that we received said that people had positive experiences at Passmores House. One person said, "It's really friendly and chilled. I can talk to anyone. Everything is explained."

They went on to say, "They don't judge you or treat you differently to anyone else."

Another person said, "The place is good and the people are good. The staff are brilliant." The person explained how they had been less successful on other rehabilitation programmes.

A relative explained how their relative's key worker, in Passmores House called a 'recovery worker' had been "brilliant" and explained, "I feel like I can trust [them] with anything."

People with whom we spoke told us that they were very satisfied with the cleanliness of the accommodation provided at Passmores House. One person told us 'I am very impressed with everything. Everywhere is clean.'

People told us that they were very impressed with the accommodation provided at Passmores House. One person told us ''The accommodation is by far the best I have seen.'' Another person told us '' Its warm and comfortable here. I have no complaints whatsoever about this place. I am very impressed.'' People told us that there were thermostats in their rooms so that they could control the temperature.

People told us that are treated with respect by staff and are able to express their views. One person told us, 'I feel that I can speak to anyone here if I have issues and I feel they will listen to me.'. Another person said, 'At first I did not agree with the rules and regulations and I rebelled against them. But now I realise that they are there for my benefit.' People with whom we spoke with told us that the weekly arrangement of a resident representative meeting with the manager was a very useful way of making comment on the service they received and that it helped them feel more involved. They also said that they found it easier to speak with someone who shared their experiences of substance or alcohol addiction and felt inspired by their success in recovery.

People told us that they were well cared for and that they received proper treatment and support. They commented positively about the holistic approach to treatment and the use of complementary therapies. One person told us, ' This is the best place I have been to by far. My detox treatment has been excellent. Medical treatment and nursing care has been great.' Another person said, 'The complementary therapies are very good and have helped me with my treatment.'

People told us that they enjoyed the food at the home and that they discussed and chose the menu at weekly house meetings. One person told us, 'The food here is very good.' Another person said, 'We all enjoy the meals here, the food is better here than any other place I have been.'

Staff take their meals with residents and this promotes a sense of inclusion. People with whom we spoke with said that they were happy that staff ate with them as it offered opportunity for engagement and helped build good therapeutic relationships

People told us that they were treated respectfully and that they could speak freely without fear of being judged or recrimination. One person told us, ' The atmosphere here is very open and nurturing and I can feel safe.'

People told us that improvements were needed. One person said, 'This place needs a cleaner. Seats and sofa are dirty and stained.'

People told us that they were happy with the way staff supported them with their medical detoxification. One person said, ' Staff really helped me in detox. They made it much more manageable than I ever expected.' Another person said, 'My medication management here could not be faulted.'

From records of people's comments made to their representative, we saw that people felt very positive about how they received treatment and medicines for detoxification. People commented that staff supported them through their substitute prescription and reduction treatment.

People told us that they liked the home but that some improvements were needed. One person said, 'We have had no central heating since Christmas.' Other people confirmed this. One person said, 'We have electric heaters in our room but they are not good. It is either too hot or freezing cold.'

People told us that there were staff available to them whenever they needed them.. One person said, ''There is always someone to speak to, even if I need to talk to someone in the middle of the night it is never a problem.''

These older reports are from our old approaches to inspection, including those from before CQC was created.

Passmores House

All Inspections

15 January 2019

During a routine inspection

19 April 2018

During a routine inspection

15 September 2016 to 15 September 2016

During a routine inspection

1 July 2014

During an inspection looking at part of the service

29 October 2013

During a routine inspection

29 January 2013

During an inspection looking at part of the service

17 July 2012

During a routine inspection

21 November 2011

During an inspection looking at part of the service

28, 29 March 2011

During a routine inspection

Reports under our old system of regulation