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Inspection Summary

Overall summary & rating

Updated 8 November 2017

We do not currently rate standalone substance misuse services.

This was a short notice announced, comprehensive inspection. However, also during this inspection we checked the progress the provider had made in addressing the breaches of regulations identified at the previous inspection in May 2016.

At this inspection we found the following improvements:

  • The provider had made improvements on the issues found in the May 2016 inspection, which related to the safety of the service. At the last inspection in May 2016 the provider's medicines policy did not offer clear guidance on how to support clients who could no longer self-administer medicines. During this inspection, the provider’s management of medicines had improved, the medicines policy now included guidance on monitoring and recording changes to client’s medicines, action to be taken by staff if a client could no longer self-administer. The policy included what staff should do if there was a medicines incident out of hours. Staff no longer stored over-the-counter medicines and the provider’s medicine’s policy indicated this.

  • At the last inspection in May 2016 we found that clients did not have appropriate risk assessments and crisis management plans. During this inspection the provider had improved clients’ crisis planning and management, this included plans to minimise the risk of overdose when clients had completed opiate detoxification.

  • At the last inspection in May 2016 we found the provider had not ensured safe staffing. During this inspection the provider had systems in place to ensure pre-employment checks were carried out and staff take up of mandatory training had improved. Staff received specialist training in substance misuse, mental health concerns and safeguarding children from abuse. The service now kept a stock of naloxone for clients at the recovery house and staff and volunteers were trained on how to use it. Staff had a good understanding of the Mental Capacity Act

  • At the last inspection in May 2016 the provider did not ensure a safe and clean environment. During this inspection, the provider had improved fire safety procedures and the service had new carbon monoxide detectors installed. The service had an improved system for infection control risk.

In addition we found the following areas of good practice:

  • Staff completed comprehensive risk assessments with clients on admission. Care records were personalised, holistic and recovery orientated.

    The service offered clients a range of psychological therapies recommended by the National Institute for Health and Care Excellence (NICE).

  • Staff had a good understanding of clients’ recovery needs. Clients reported staff treated them with dignity and respect. We observed good interactions between staff and clients and this impacted positively on client’s recovery. The service offered treatment to clients who were in need with no access to funding through the provision of a bursary.

  • Senior management were visible throughout the service. Clients and volunteers fedback that they knew who the senior management were and worked closely with them. Volunteers received regular supervision from management. Staff and volunteers had worked at the service for a number of years and turnover was low.

However, we also found the following issues that the provider needs to improve:

  • At this inspection, we found the provider did not have appropriate systems in place to assess client’s ability to self-administer their medication upon admission. Although, the provider had made effective changes to the management of medicines policy and procedures these had not been fully embedded yet.

  • Although staff reported safeguarding concerns to the local authority, the provider did not have a policy in place for notifying the CQC of incidents. Managers and staff were not aware that they needed to notify the CQC of incidents. 

  • The service’s admissions policy did not clearly describe the criteria for accepting a client with complex mental health needs.

  • Staff did not conduct regular monitoring of the quality of care and treatment provided. This meant staff could not monitor and improve the running of the service.
Inspection areas


Updated 8 November 2017


Updated 8 November 2017


Updated 8 November 2017


Updated 8 November 2017


Updated 8 November 2017