Archived: Brook Drive

Updated 10 February 2022

We undertook this unannounced comprehensive inspection of Brook Drive following information of concern regarding the treatment of clients in the service.

The service provides residential drug and alcohol detoxification treatment to all adults. It has 26 beds.

Brook Drive is registered to provide Accommodation for persons who require treatment for substance misuse and Treatment of disease, disorder or injury.

There was a registered manager in post at the time of the inspection.

We last inspected Brook Drive in November 2018. At that time, we rated the service as Good in all areas and Good overall.

What people who use the service say

The five clients we spoke with were very positive regarding the support they received from staff. Clients said that staff were very helpful and understanding. Staff were supportive, developed good relationships with clients and treated clients as individuals. Clients also said that staff were good at motivating them to remain abstinent from substances and responded when clients needed support.

Two clients specifically mentioned that the cook was good and the food was very good.

Updated 10 February 2022

Our rating of this location went down. We rated it as inadequate because:

Our rating for this service has been limited by the enforcement action we have taken. We imposed urgent conditions on the registration of this service under section 31 of the Health and Social Care Act 2008. This means the service can only admit clients when there are experienced, qualified and suitable medical staff always available. The service can only admit clients whose needs it can safely meet. We also served two warning notices on the provider, concerning safeguarding clients and governance.

We found:

• The service admitted clients with serious and significant physical and mental health problems, which the service could not safely provide care and treatment for. There was no inclusion and exclusion criteria for the service. Since the beginning of 2021, 13 clients had been transferred by emergency ambulance from the service to hospital.
• Staff did not have an understanding of safeguarding and did not know how to make a safeguarding referral. No staff had undertaken safeguarding children training and only 25% had recently undertaken safeguarding adults training. Two incidents which should have prompted a safeguarding referral had not.
• Not all medical staff had qualifications to safely treat clients with complex problems in the service. Medical staff did not receive supervision for their substance misuse work. Clients’ mental health and cognition was not adequately assessed on admission. There was no psychiatrist working in the service to assess and support clients with mental health problems. Out of hours medical cover consisted of medical staff who did not have specific experience in substance misuse treatment and detoxification.
• There were frequent occasions when there were not enough staff on shift. It was common for there to be a shortage of registered nurses on shift. There was no system for assessing how many staff were required to support clients.
• The governance system for the service was ineffective. Safeguarding and complaints were not standard agenda items at meetings, there was a lack of clinical audits and limited learning from incidents. There were no prescribing protocols. The service risk register did not include the risks we identified during the inspection. There was no single document or system for managers to have oversight of staff mandatory training. Almost without exception, less than 50% of staff had undertaken mandatory training.
• Staff did not understand the Mental Capacity Act 2005. When clients were intoxicated on admission their capacity to consent to admission and treatment was not assessed.
• Clients’ care plans did not identify their specific needs during treatment.
• The service did not notify the CQC of incidents which it was legally required to. These incidents concerned serious injury to clients and alleged abuse.

However:

• Staff treated clients with compassion and kindness. Staff were supportive, developed good relationships with clients and treated clients as individuals. Clients said that staff were very helpful and understanding.
• Eighty per cent of clients completed treatment and had a planned discharge from the service.
• Staff were positive regarding the manager of the service and their leadership style. They said that the culture of the service had improved during the previous year.
• Staff in the service had undertaken an audit of clients who had alcohol withdrawal seizures. The number of clients having seizures had reduced.
• When clients were unable to obtain support for their pet during their detoxification treatment, they could bring their pet into treatment with them.

Updated 10 February 2022

See overall summary.