During an assessment of Residential substance misuse services
We rated the service Requires Improvement because we found 3 breaches of regulations in relation to premises and equipment, governance, and staffing.
We found that the environment was not consistently maintained. Some areas and furnishings were not clean and posed safety risks. Cleaning products were not always stored safely, and cleaning and monitoring practices were not consistently effective.
The service did not have clear governance processes to ensure resident safety through the use of Personal Emergency Evacuation Plans. There was a lack of effective oversight in relation to cleanliness, the environment, and implementation of some policies. Service leaders did not ensure staff received all required training in learning disability and autism, updated adult safeguarding Level 2, or had regular appraisals.
However, the service had enough staff to support residents. When additional cover was needed, the provider used bank staff who had existing or prior experience with the service. This ensured familiarity with provider procedures and supported consistency of care.
Residents spoke positively about the therapeutic programme and the staff who supported them. They said they felt safe and understood the contract commitment required to engage with their recovery journey during their admission.
Stakeholders and family members gave positive feedback about the recovery progress they saw residents making and they noted the support given to residents to develop healthier lifestyles. Stakeholders described the service as effective and responsive, and highlighted strong resident-staff relationships, and its development of a network of recovery peers and mentors.
Mental Capacity Act / Consent to Treatment Overview
Residents consented to care and treatment on admission. Residents’ mental capacity was assessed prior to admission, and the service did not admit residents who lacked capacity to engage with the recovery programme. We reviewed care records and saw that all residents were asked mental capacity assessment questions on admission, and these were recorded in the care record consent section.
The provider had a mental capacity policy in place. Staff had not received mandatory Mental Capacity Act training. However, staff we spoke with were able to describe what to do if they had concerns about a resident’s mental capacity, including reporting this to the referrer or to mental health services. Staff consistently supported residents to make decisions about their care and recovery plans.