Archived: FOCUS12 - Treatment Centre

Updated 4 September 2018

Focus 12 is an independent charity established in 1997 in Bury St Edmunds. This was a community based treatment centre, which offered detoxification from both drugs and/or alcohol under staff supervision. The primary treatment was offered over a 12-week period. The provider delivered ongoing abstinence based treatment, which included group therapy and individual counselling. In addition to the treatment centre, Focus 12 also had three residential accommodations, where clients who were receiving treatment resided. These were all located in Bury St Edmunds.

When we inspected the service in May 2016 we found the service was not meeting regulations. Enforcement action was taken under Regulation 12 Safe Care and Treatment and Regulation 19 Fit and proper Persons. We also issued a requirement notice under Regulation17 Good governance. When we re-inspected in January 2017 we found that the provider had made some progress and had met the requirements of the warning notice.

We carried out an unannounced inspection on 05 March 2018 following concerns being raised with us about the service. We found the service was not meeting regulations. We began enforcement action and issued a warning notice under Regulation 12 Safe Care and Treatment and Regulation, regulation 17 Good Governance and regulation 19 Fit and Proper Persons. We told the provider that they must comply by 31 May 2018. We issued additional requirement notices under Regulation 12 Safe Care and Treatment, Regulation 17 Good Governance and regulation 11 Need for Consent.

We carried out a further unannounced inspection on 19 and 20 June 2018, to check whether the provider had met the warning notice requirements. We found that the breaches of regulation had not been addressed. Following this the provider gave an undertaking to meet all regulations by 20 July 2018. In addition, the provider voluntarily suspended all detoxification at the service. We returned to the service on 28 June, 16 July and 24 July 2018 to check on progress and ensure that clients were safe. On 24 July 2018 we found that the provider had not fully complied with all regulations.

The Care Quality Commission did not take further action against the provider because following the inspection, the provider told us that they intended to cease treatment and de-register the service.

The service was de-registered by CQC on 8 August 2018.

Updated 4 September 2018

We do not currently rate independent standalone substance misuse services.

We found that the provider was in breach of regulation and the following issues that the service provider needed to improve:

• The provider had not acted on all areas of concern we had raised following previous inspections. Some of these issues had first been raised with the provider in 2016. The provider had therefore failed to fully act or maintain improvement to meet regulatory requirements.

• There were no environmental and fire risk assessments in place for the premises. Therefore, risks at the premises had not been identified.

• There were insufficient staff to meet the needs of clients. Staff were tired and overstretched and working outside of their contracted hours. The provider had not ensured that pre-employment checks were in place for all people working at the service.

• Policies and procedures for medicines management were not fit for purpose, in date and did not reflect best practice. The provider had not ensured the safe management of medication including controlled drugs.

• There were frequent gaps in client records and these were not updated in a timely manner. We found there were discrepancies in the accuracy of records where an emergency had occurred. Clinical information systems were not robust.

• Client’s had been admitted to the service whose clinical needs could not be met. Staff did not have clear instruction regarding how to manage emergencies.

• There was not a robust system for incident reporting, reviewing, learning and feeding this back to staff. Safeguarding concerns had not been reported to the local authority.

• While governance systems were in place meetings had not occurred as scheduled. A draft risk register was put in place but this did not identify all risks to the organisation. There was no programme of audit to ensure that improvements were made to the service when concerns were identified.

We found the following areas of good practice:

• We saw evidence of some involvement in care plans. Staff communicated with clients regarding their treatment.

• Clients could feedback to the service on the treatment they received.

• Clients were positive about staff at the service.

• The staff files reviewed showed managers had carried out and documented staff appraisals.

Updated 4 September 2018