Abbington House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm. This is the first inspection for this newly registered service.

We rated safe as requires improvement because the service did not always have a proactive culture of safety. We requested duty of candour records but did not receive any evidence of duty of candour when things went wrong. Systems, pathways and transitions were not always safe. Medical summaries were not always present in client care notes and prescriber appointments on admission were not always face to face. Processes and governance to ensure safe staffing were not always in place. Not all staff had appropriate checks when starting their employment. There were also gaps in mandatory training. Infection prevention control processes were not always safe. The services clinical room did not have sink for hand washing or an examination couch. The environment was not always safe. The services fire policy had not been approved and was in draft version, although there was a fire risk assessment in place. Staff were not aware of ligature points at the service. Medications were not safely disposed of in a timely manner and naloxone was locked away and was not easily accessible in an emergency. The service was not always using recommended clinical tools to support clients in their treatment.

However, lessons learned were discussed with the team and changes were implemented. The environment was clean and there was a cleaning rota in place. The service had good links with their local pharmacy who supplied medications for clients having detox at Abbington House.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff did not always have a proactive and positive culture of safety. There was no evidence that staff had completed duty of candour training. We did not see any evidence of duty of candour records when something went wrong. We did not see any evidence that an apology was given to clients following an allergic reaction to food or after a choking incident. Duty of candour mandates health and social care providers to be open and honest with clients about their care and promotes a culture of learning. However, client feedback about the service was that they felt safe and cared for.

We reviewed the service’s monthly incident and analysis framework, where monthly incidents were reviewed to see if there were any themes and to identify learning following an incident. Incidents recorded included falls, seizures, a choking incident and a medication error. There was an incident where a client had a seizure. Learning identified from this incident was that observations of clients going through detoxification should be increased. Staff told us that learning was shared in staff meetings.

Staff told us that they had switched to using paper medication administration recording charts (MAR) due to issues with electronic system recording. We found recording of medication administration was completed well. Managers made changes when existing processes were not working to increase safety of medication administration.

We did not always see safe systems in care. We reviewed 6 client care records. Consent to share information did not include sharing information with other agencies and professionals. This meant that there may not have been joint working alongside other agencies to ensure client safety. Three client records had evidence of consent to treatment and sharing information.

Admission procedures were not always safe. Medical summaries and blood test results were not always present in client records that we reviewed. Therefore, information concerning a client’s health was not always known on admission, meaning that clinical decisions were not always safe. Staff told us that clients would be taken to hospital if blood results were needed.

Systems were not always safe when clients were admitted to the service. For example, staff told us that some initial prescriber appointments were completed online and a face-to-face appointment would be arranged when the prescriber was available at the service.

The service had an admission and discharge policy in place and an admission checklist to refer to when admitting new clients. The admission and discharge policy stated criteria for admission and processes for planned discharge and for discharge in an emergency. The policy was brief and there was not a detailed process for staff to follow.

We also reviewed unexpected discharge planning. We saw some individualised plans for early discharge, including drug safety, support from next of kin and encouraging clients to stay. However, not all unexpected discharge plans were personalised and did not always include support from external agencies. This meant that clients were not always getting appropriate support when leaving the service

However, the service had good links with their local pharmacy. The pharmacy supplied medications for patients having detoxification at Abbington House. Staff told us that clients could temporarily register with a local GP to support their physical health needs.

Sixty eight percent of staff at Abbington House had completed safeguarding adults training. The service had a safeguarding lead in place. However, not all members of staff were able to tell us who was responsible for safeguarding. Therefore, safeguarding procedures were not embedded in the service.

Managers told us that clients were encouraged to meet children outside of Abbington House, rather than children coming to the service. Staff told us that safeguarding policies were easily accessible. Staff were able to tell us about a time when they had needed to complete a safeguarding referral due to concerns over a child's safety.

There was a safeguarding register in place, which detailed the concerns and actions that had been taken when safeguarding concerns were raised.

Clients told us that they felt safe at the service. One client told us that they had been checked by staff every hour on their first night. This was to check that the client had not gone into alcohol withdrawal.

Client's risk assessments were not always reviewed by the specified date, meaning that risks documented were not always current. However, all clients had a comprehensive risk assessment in place. Risk assessments provided detail about substance use, physical health, mental health, risks such as domestic abuse, harm to children and finances.

There was limited information sharing within multi-disciplinary meetings or with other professionals. Multi-disciplinary discussions to discuss risk were not documented in client care notes. Discharge planning did not include information sharing with the clients GP or local drug and alcohol agency to manage risk after discharge from treatment.

Clients told us that they felt safe and were able to give examples of when they felt their risks had been managed well by staff. For example, one client told us that staff had observed them regularly throughout the night on admission to the service.

The environment was not always safe. We did a tour of the environment and found there were multiple ligature anchor points. The providers admission and discharge policy made no reference to exclusion criteria for clients who are at risk of self harm and or suicide, however there was a ligature risk assessment in place.

We reviewed patient risk assessments and found evidence of a recent suicide attempt prior to admission. Staff were not aware of the highest risk ligature anchor points. Since our inspection managers have told us they will discuss ligature anchor points at team meetings to ensure all staff are aware.

There were areas of the building that were not well maintained. There were holes in the walls where curtains had been replaced with blinds and the holes had not been filled. We observed the disabled toilet in the main building. There were lockers, a folded wheelchair and other property in the disabled toilet. This was not suitable for use. We reviewed the fire risk assessment for Abbington House. The service’s fire policy was a draft and had not yet been approved meaning that procedures for an emergency were not embedded. However, there was a fire risk assessment in place.

Staff told us they had a cleaning rota in place to complete daily cleaning tasks. The environment was clean and there were locked cupboards containing cleaning products. All equipment had been PAT (portable appliance testing) tested to ensure it was safe to use.

Contingency plans were in place, for who to contact should there be a failure or breakdown of equipment including gas, electricity, plumbing and water, as well as contact details for senior managers.

We reviewed training matrix and found gaps in mandatory training completion. We found 68% of staff had completed their induction. Two members of staff had completed training in alcohol misuse and 3 members of staff had completed training in drug misuse. Supervision compliance was 78% at the time of inspection.

Staff told us that most members of the team would be able to administer naloxone in an emergency, however not all members of staff had been trained in how to use naloxone. Naloxone is used for the emergency treatment of known or suspected opioid overdose.

The service did not have a registered nurse in post. However, the service did have enough staff to meet people’s needs. During the day this included 8 support workers, a senior support worker, 3 therapists, 2 doctors that attended the service when needed, a manager, assistant manager and treatment director.

Infection prevention and control policies were not always followed. We reviewed staff meeting minutes, which stated that staff should smash up drug paraphernalia if found on site and put remnants of the paraphernalia in the clinical waste bin. This is not in line with infection prevention and control policy and is not safe practice.

We observed the clinic room, which did not have hand washing facilities or examination couch. It was unclear where the doctor would complete examinations with clients if needed.

Managers told us there was a cleaning rota in place in the absence of a cleaner. The environment looked visibly clean.

There were two chefs at Abbington House and both had completed mandatory training in food hygiene. Following an incident where a patient had an allergic reaction to food, training in allergies and anaphylaxis had not been completed, although was not mandatory.

The provider did not have a safe process in place for disposing of medications once a client had been discharged. We observed medicines for 3 different patients in a locked cabinet that needed to be returned to the pharmacy for safe disposal. Unused medications should be disposed of to prevent potential harm.

Leaders told us that they had received training from a local drug and alcohol service on how to administer naloxone in the event of an opiate overdose. Naloxone was available at the service, however it was in a locked cabinet which meant it was not easy to access in an emergency. Not all staff were trained in how to administer naloxone in an emergency.

However, prescribers made good detoxification plans with clients and the service had good links with their local pharmacy.