The Care Quality Commission
  • Residential substance misuse service

Archived: PCP Leicester

Overall: Requires improvement read more about inspection ratings

158 Upper New Walk, Leicester, Leicestershire, LE1 7QA (0116) 258 0690

Provided and run by:
PCP (Clapham) Limited

All Inspections

04 - 05 November 2019

During a routine inspection

We rated PCP Leicester as requires improvement because:

  • The provider had not met legal requirements in relation to controlled drugs. Staff had not identified, through clinic room audits that the service was operating without a controlled drugs Home Office Stock licence between 30 August and 08 September 2019. This had not been picked up as part of the providers clinical audit process.
  • Staff did not always respect client’s privacy and dignity. We observed on two occasions that staff were taking clients physical observations in the reception area, even though there was a clinic room for these procedures to take place in private.
  • Mangers did not formally supervise new starters they had been post for three months. While this was in line with provider policy and there were other informal measures in place to ensure staff were not left unsupervised during their first three-month probationary period. We had concerns as the impact of this could be that new staff may encounter skills deficits or develop poor practice before they were formally picked up through the supervision process.
  • The provider did not always ensure the safe disposal of clinical waste. There was no yellow clinical waste bin in the clinic room, though there was one in the toilet where staff did urine testing. We raised this with the manager and before we left site she had ordered a second clinical waste bin.

However:

  • The service was well led, and the governance processes had been reviewed to ensure that its procedures ran smoothly. Since our previous inspection the provider had restructured the service to include four senior managers including an operational manager, a health and safety manager, compliance manager and services manager. The registered manager no longer carried any clinical responsibility.
  • The service provided safe care. The clinical premises where clients were seen were safe and clean. The service had enough staff, this was an improvement on our previous report. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the clients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • Staff treated clients with compassion and kindness and understood the individual needs of clients. We heard some exceptional examples including how staff had supported and encouraged a client who wanted to leave on their first day at the service, the client decided to stay; staff liaising with a client’s employer to keep their job open for them whilst they underwent treatment; staff supporting clients to regain contact with their estranged children and the provider extending a client’s stay free of charge.
  • Staff actively involved clients in decisions and care planning. Clients told us the service was easy to access. Staff planned and managed discharge well and had alternative pathways for people whose needs it could not meet.

03 July to 04 July 2018

During an inspection looking at part of the service

We do not currently rate independent standalone substance misuse services.

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

  • Overarching governance of the service was not embedded practice. Management did not monitor new guidance and policy to ensure it was effective. Management did not evaluate and check their quality improvements for effectiveness. The service did not have targets or key performance indicators. Quality assurance management and performance frameworks were not in place. The risk register was incomplete. Registered managers did not have sufficient time, authority or autonomy to carry out their duties effectively. Communication between senior management and location managers and staff was not always good. Not all recruitment processes were robust. The provider did not have clear vision and values.

  • Poor cleanliness due to lack of monitoring in the communal kitchen area posed a risk of infection for staff and clients. Managers had not included blind spots on the environmental risk assessment.

  • Management had not completed clinical audits. There were no external audits of the processes relating to medicines management and dispensing medication for the three months prior to inspection. The medications policy did not reflect amendments to the health and social care regulations or current guidance around medication management. There was no controlled drugs accountable officer for the service, and in the absence of a drugs accountable officer the provider had not addressed the need to work in partnership with a local pharmacist, or the local controlled drugs accountable officer group.

  • Following a medication error management had, considered this to be due to human error and not made any changes to practice. However, they had not considered what changes would reduce the chances of the human error occurring in the future.

  • We expressed concern about the providers practice of accepting new referrals on a Friday morning for detoxification over the weekend, when there were no clinical staff on site.

  • Three clients and two family members we spoke with were not happy that staff had not invited them to view the accommodation prior to admission or signing their treatment agreement.

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

  • The treatment centre had enough staff to provide safe treatment. Staff and doctors had completed comprehensive risk assessments for all clients. Risk assessments included processes to follow for a client who unexpectedly exits treatment. The service rarely cancelled appointments or groups due staff shortages or sickness.

  • Staff and doctors completed full mental health and physical health assessments for all clients. Treatment plans were holistic, personalised, and identified client’s strengths and existing coping strategies. Care plans and risk management plans reflected the diverse and complex needs of clients including clear care pathways to other supporting services and support for clients with the transition back to community living.

  • Doctors followed good practice in managing and reviewing medicines including following British National Formulary recommendations. The service had embedded relevant National Institute for Health and Care Excellence guidelines. Staff used recognised treatment outcome measures, therapy and support staff had attended specialist training.

  • Clients told us access to the service was easy and efficient. The opportunities for their families to be involved and supported during their treatment and the aftercare offered by PCP Leicester were some of the best they had encountered. Furthermore, we saw 21 feedback forms 17 of which praised the staff and the treatment programs offered.

29 to 30 March 2017

During a routine inspection

We do not currently rate independent standalone substance misuse services.

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

  • Clients, who did not understand English to an adequate standard had to pay for their own interpreters to access parts of the treatment programme.
  • The service only had contracted medical cover for nine hours per week, and there was no specialist detoxification urgent medical cover for evenings and weekends.
  • The lone worker policy required review, to ensure that it was specific to the work and processes carried out at PCP Leicester. In particular with regard to how staff and clients could and should efficiently and quickly access emergency help if required at weekends.
  • Interview rooms were not fitted with alarms and staff did not carry personal alarms.
  • The ligature audit was incomplete, and currently not fit for purpose.
  • The fridge in the kitchen area used by staff and clients did not have a thermometer fitted or any temperature monitoring records. Open food items were not dated or labelled.
  • The establishment of a fire warden and the processes attached to the role including properly monitored and recorded fire drills needed formalising and promoting within the service.
  • There was no designated first aider. The policy and practices relating to access for emergency first aid required formalising and promoting within the service.
  • Staff did not complete records to show medical equipment had been calibrated.
  • The provider had decided to not backfill the registered nurse post for a temporary period. Therefore the service only had nurse cover for three days per week, instead of the established five days.
  • There was no external or independent verification of the weekly and monthly medication audits including those relating to controlled drugs audits. Clients did not sign the medication log to confirm they had received their controlled drugs.
  • The services vision, values and mission statement was not clear.
  • Clients would not be able to discharge themselves safely between 5.00pm and 8.30am during the first week of treatment, as they would not be able to access their mobile phone, money or other valuables, to facilitate this.
  • There was no policy relating to the safeguarding of children while visiting relatives at the therapy unit.

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

  • Staff were dedicated and passionate about putting the clients first and wanted to provide the best possible therapy program they could.
  • Clients told us that access to the service had been easy and efficient.
  • All clients had an initial risk assessment and all risk assessments had been updated within the past month. Risk assessments were comprehensive and included process to follow for a client who unexpectedly exits treatment.
  • Staff induction, training, supervision and appraisal met with the provider’s policy. Case reviews and team meetings were embedded in practice and well attended.
  • The service had developed a culture of wanting to learn from incidents and feedback, they had recently introduced “care plan Thursday” in response to feedback.

17/11/2015

During a routine inspection

We do not give a rating for specialist services. We found action was required because:

  • The service would have benefitted from having some additional medical equipment. There was no emergency or medical equipment on site and the medication fridge did not have a lock or temperature gauge. However, the environment was clean, and regular environmental risk assessments took place.
  • Not all staff had completed their mandatory training or engaged in the additional training on offer. Personnel files did not contain evidence of regular supervision or appraisal meetings to monitor staff performance and we saw evidence that people not yet employed by the service, and so were working as volunteers without appropriate checks in place, had dispensed medication to clients. However, staffing levels were adequate, and provided a mix of counsellors, one nurse and two doctors.
  • The service had only just opened a general incident log at the time of our inspection. Prior to this, they had only been recording serious incidents. There had been no serious incidents in the last 12 months at this location, but there was no forum to discuss learning from incidents at other locations.
  • The building was not accessible by wheelchairs; the provider had another disabled user friendly.
  • The service did not use robust recruitment processes. References were not always appropriate and did not meet the requirements of the service policy. The provider did not follow policy around recruitment and did not assess Disclosure and Barring Service (DBS) forms for the potential risks of employing candidates.
  • Staff did not always feel informed of incidents occurring in other locations, and lessons learnt from this. They felt this compromised their opportunity to improve this service as a result.

However:

  • We observed robust risk assessments, which were detailed and holistic. There was a robust policy in place around children visiting clients in treatment.
  • Clients received holistic assessments, and had a medical assessment within 24 hours of being admitted to the clinic.
  • The service uses national outcome measures to monitor client progress through treatment, which was based on the 12 step methodology.
  • Staff were trained in and confident in their approach to the Mental Capacity Act.
  • Staff treated clients with kindness and respect. We saw that staff understood individual needs and were aware of client’s preferences. Clients said they felt safe when using the services.  
  • The service had a clear policy around access and discharge, and what to do in case of an unplanned exit from treatment. Clients said they felt able to complain if they felt the need to, although the clients we spoke to said they were very happy with the care they were receiving.
  • Recent changes to the service had a positive effect, such as the recruitment of a nurse and a compliance manager.