Aspinden Care Home

We do not currently rate independent standalone substance misuse services.

This was an unnounced, focused inspection, where we looked at whether the provider had made the required improvements that we said it must at our previous inspection in June 2017.

Following the June 2017 inspection the provider voluntarily agreed to stop new admissions. In addition, two warning notices were served relating to Regulations 12 safe care and treatment and 17 good governance.

At this inspection, October 2017, we found that some improvements had been made , but that further improvements were needed, including the embedding of new systems introduced since the last inspection.

We served a warning notice relating to Regulation 15 premises and told the provider if must ensure premises were clean and safe. In addition, we asked the provider to continue not to admit new patients until further improvements had been made. The provider agreed to do so until February 2018.

We found the following areas that require improvement;

• Systems to ensure the cleanliness, hygiene and maintenance of client bedrooms and bathrooms were not effective. Some areas of the service smelt of urine and bathrooms were in need of refurbishment.

• CCTV had been introduced in the entrance of the building.However, systems to monitor who entered and left the building were not robust and did not ensure the safety and well-being of clients and staff. In addition, staff could not see into the ‘wet room’, which was the communal living area where clients were able to smoke and drink.

• Staff were not taking appropriate action when fridge temperatures fell out of range and the majority of staff had not had their competence to administer medicines assessed.

• Further improvements were needed to ensure that risk assessments were updated following changes in client presentation, for example following a hospital admission.

• Further improvement was needed in how client’s physical health care needs were managed.Communication with the visiting commuity nursing team needed improvements to ensure clients needs were met.

• Systems to share learning from incidents with staff were not in place.

• There were a number of fire safety actions that still needed to be addrerssed. Personal evacuation plans for clients with mobility issues did not meet their needs. A fire door within the premises had been locked, which meant that the safety of clients and staff had been compromised.

• Improvements were needed to ensure that observation were carried out in the ‘wet room’ when they were due according to smoking risk assessments.

• Whilst monitoring of mandatory training had improved, staff take up of the majority of mandatory training was below 75%. Not all staff received supervision regularly.

• We found that there were no capacity assessments in place for clients where there were  areas of concern regarding capacity other than DoLs authorisations. Records showed that only half of the staff team had completed mental capacity training.

• The provider had not implemented changes required to ensure it was delivering care in accordance with guidance on same sex accomadation although had considered how it might implement this.

• Staff needed to ensure that all incidents were reported, including incidents of verbal abuse towards staff.

  However, we found the following improvements had been made since our last inspection in June 2017:

• Medicines management and administration had improved, but the revised systems needed further embedding. The service now had risk assessments for client’s self- administering medication and were completing medication audits. The majority of staff had completed medicines training

• Processes for identifying, assessing and managing risk had improved. All clients had a risk assessment in place, including moving and transferring.

• There had been improvements in communication with community psychiatric nurses. A revised GP contract was about to be introduced, with the aim of improving physical health support to clients and improving communication with staff.

• A fire safety assessment had been completed; regular fire alarm tests and evacuation drills were being carried out.

• Observation of clients at risk had improved. The service had fitted CCTV into all communal areas. Clients were now regularly observed at a minimum of hourly.

• New systems to identify who was supervising which staff had been introduced, along with a standardised supervision template.

• A permanent manager had been appointed and arrangements were in place for them to receive a handover from the acting manager.

• The service had developed a detailed referral form. They had introduced drug and alcohol stars. These were used to document discussions with clients regarding how they wanted to be supported with managing their alcohol intake. These were detailed and person centred. Staff had identified and managed clients nutritional and hydration needs.

• Staff had completed safeguarding training, were able to tell us how to make a safeguarding referral and safeguarding information was clearly displayed for both clients and staff to see. All safeguarding concerns had been appropriately considered with alerts made to the necessary stakeholder organisations.

• An audit programme had been introduced.

• Staff were committed to the clients and to the service. Staff felt that managers were open and approachable. Staff were positive about the changes they had seen taking place since the last inspection.

We do not currently rate independent standalone substance misuse services.

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

• The service did not have an effective model of care in place. The service stated that they were following a harm reduction model of care. However, there was no clear service model in place which included what the aims and objectives were of the service and how harm reduction was going to be achieved. There were no clear procedures in place which stated how the harm reduction approach would work in practice. Clients did not have contracts or agreements in place as to how to support them with harm minimisation.
• A stable leadership team was not in place. The registered manager had been away from the service for nearly six months and whilst an acting manager was in place the long term plans were not clear. The provider had not ensured that the manager was appropriately supported to maintain the safety and quality of services.
• The provider did not have established systems in place that provided assurance that the service was appropriately meeting the needs of the clients, following up concerns raised by other stakeholders and using audits to maintain standards within the service.
• The service did not have clear criteria for admission. The service was not ensuring that comprehensive assessments were undertaken before admission. This meant that clients were at risk of receiving care that was not safe or appropriate and did not meet their needs.
• There was not sufficient staff to ensure there was safe care and support for clients. We saw from client’s records that some clients required support from two staff for their personal care needs. Staff shifts were unfilled; there were some night shifts where there had only been one member of staff working. The service did not have a system in place to be able to measure staffing levels to ensure they were safe.

• Robust safeguarding processes were not in place. The provider did not have records to show if staff had completed mandatory safeguarding training or not. The service did not have safeguarding information on display about how to make a safeguarding referral. Not all staff were able to tell us how to make a safeguarding referral. Safeguarding was not discussed as a regular agenda item at staff meetings or at the senior management incident sharing meeting. The incident form did not record if a safeguarding referral had been made.

• Risk assessments were not updated following changes in clients’ needs and did not always contain all the relevant information regarding clients’ risks. The service had not raised serious incidents following safeguarding alerts being made by the local hospitals regarding the potential neglect of clients .The provider held a meeting to discuss incidents; however the actions from these meetings were unclear. There was not a process in place to discuss feedback from incidents with staff or clients. There was not a system in place to ensure that learning from incidents occurred.
• There were significant fire safety concerns at the service. The service had not implemented an action plan put in place after the London Fire Brigade had been called to the service in March 2017. Significant areas for action to ensure fire safety remained outstanding, including the development of personal evacuation plans for clients with mobility issues or who may have been drinking. The service had not recorded that a fire drill had been carried out during the previous year. Fire alarm tests had not been carried out regularly during 2017
• At the previous inspection in September 2016 we found that the service did not have appropriate systems in place to manage medicines. There was no controlled drug register, risk assessments for client’s self-administration or completed medication audits. At the current inspection we found that the service still did not have the appropriate systems to manage medicines. There was a controlled drug register in place. However, the service did not carry out risk assessments for clients self-administering medication or complete medication audits. The service did not have records of staff completing training in medicines management.
• At the previous inspection in September 2016 the service manager was not clear on the training needs of the staff and the service did not have an efficient system in place to record mandatory training compliance rates or specialist training rates. At the current inspection we found that the service still did not have a system in place to record mandatory training compliance rates or specialist training rates. This included safeguarding and mental capacity act training.
• At the previous inspection in September 2016 we found that staff did not always ensure clients had comprehensive care plans to address all identified needs. Clients with epilepsy did not have specific care plans or risk assessments in place for the safe management of their epilepsy. At the current inspection in June 2017 we found that staff did not always ensure that clients had comprehensive care plans to address all identified needs. Clients with epilepsy did not have specific care plans in place for the safe management of their epilepsy. Clients did not have care plans for their individual needs such as their personal care needs, moving and transferring needs or how to support them with ensuring their rooms were clean. Clients did not have a copy of their care plans which were in an accessible format.
• At the previous inspection in September 2016 we found that the service did not document agreed decisions made with clients around restricting their alcohol and finances. At the current inspection in June 2017 we found that there had been no improvement and the service was still not implementing a robust process for supporting clients to manage their alcohol misuse and documenting agreed decisions with clients around restricting their alcohol.

• The provider was not ensuring that that the physical health care needs of clients were met. The provider did not ensure that risk assessments and care plans were updated to include information regarding physical health care when client’s needs changed. The provider did not ensure that visits from health care professionals were clearly documented with the agreed actions and outcomes of these visits.

• The service was not able to ensure the safety of the clients in the communal areas of the building. The service did not have appropriate security at the front entrance and it was not possible to accurately know who was entering or leaving the building. Staff could also not observe communal areas. Staff were not observing clients using the ‘wet room’, which was the communal living area where clients were able to drink and smoke. We observed clients who had been drinking heavily in this room. This meant clients were at risk of injury and abuse.

• The service did not have a same sex accommodation policy in place and had not considered separation of bedroom and bathroom facilities according to gender.

• The provider did not respond appropriately when clients’ needs changed and the service was no longer able to meet their needs.

• The service was not using the Mental Capacity Act appropriately. Staff did not document when there were concerns regarding capacity, there were no capacity assessments in place. There were no records that staff had completed mental capacity training.

• The service did not support staff by ensuring that they had regular supervision. The service did not supply staff with personal alarms so that they could call for support if needed.

• The service did not support clients to clean their rooms on a regular basis.

Following the inspection a notice of proposal was served proposing that no more clients were admitted to the service until the issues of concern were addressed. This was voluntarily accepted by the provider who has stopped admissions. In addition two warning notices were served relating to regulations 12 safe care and treatment and 17 good governance.