No 4

At a previous inspection in May 2019, we identified concerns about safety and quality of the service which put clients at risk of harm. The service was rated as inadequate overall and was placed into special measures. Following the inspection in May 2019, the service made the decision to not admit any clients for alcohol detoxification who had a history of alcohol withdrawal seizures and delirium tremens.

During this inspection our rating of the service improved. We rated each domain as good and the service overall as good. As a result of this inspection, the service was removed from special measures.

We rated No 4 as good because:

• The service provided safe care. The clinical premises where clients were seen were safe and clean. The service had enough staff. 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.
• The teams included or had access to the full range of specialists required to meet the needs of clients under their care. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and relevant services outside the organisation.
• Staff treated clients with compassion and kindness, and understood the individual needs of clients. They actively involved clients in decisions and care planning.
• The service was easy to access. Staff planned and managed discharge well and had alternative pathways for people whose needs it could not meet.
• The service was well-led and leaders had the skills, knowledge and experience to perform their roles.

However:

• Forty-five percent of clients using the service did not give permission for the provider to obtain or share information from their GP. Whilst the service had measures in place to mitigate the risks associated with this, they recognised that to improve the overall safety of the service further work was needed.
• The provider did not have a system in place for staff to raise an alarm from within the clinic room in an emergency.
• Further work was needed to strengthen the providers audit programme to ensure that outcomes were consistently rated across the range of measures used and that the sample included clients who had completed each of the various treatment pathways.
• The provider had recently strengthened its governance systems. Further work was needed to ensure that these were embedded and sufficiently robust to drive quality, safety and improvement in the service.

We rated the service inadequate overall because:

• The service provided medically monitored residential substance misuse detoxification treatment and psycho-social rehabilitation services.

• At the time of inspection there were no clients resident within this property, although it was still accessed by staff. Therefore, we could not gather sufficient evidence to answer three of the key questions.

• We were concerned that the provider had not full taken account of a CQC briefing (supported by Public Health England) on the quality and safety of detoxification in residential substance misuse services. This was circulated to providers of all relevant services in 2017 and it remains on our website: https://www.cqc.org.uk/sites/default/files/20171130_briefing_sms_residential_detox.pdf

• The service did not provide safe care for clients undergoing alcohol detoxification. The provider accepted clients for alcohol detoxification who had a history of alcohol withdrawal seizures and delirium tremens. This carried a level of medical risk that was not fully assessed prior to admission.

• Clients did not have a comprehensive assessment before commencing alcohol detoxification treatment. There was no record that clients had a physical examination, including clients with a reported physical health problem. This included clients with possible or actual liver disease.

• Clients did not have a cognitive assessment. This meant clients were not screened for Wernicke’s encephalopathy. Wernicke’s encephalopathy can result in irreversible brain damage if left untreated.

• Clients were not asked about, or offered, screening for blood borne viruses, such as hepatitis and HIV.

• Clients’ medical and mental health history was not always obtained from other healthcare professionals prior to detoxification treatment. This meant important information concerning clients’ health was not always known. When clients refused to consent for the service to contact their GP, there was no record to show a clinician had reviewed the decision to make sure it was safe to provide treatment without this information.

• Environmental and health and safety risks were not managed. Actions recommended in a fire risk assessment dated March 2017 had not been actioned. Due to our concerns we requested an urgent visit from the fire safety officer from the London Fire Brigade. They carried out a visit on the 3 May 2019. They have told us they are taking further action.

• The service did not have effective systems for the appropriate and safe use of medicines, this put people at risk of receiving unsafe care and treatment. The service’s medicine policy did not address all relevant areas. There were no prescribing protocols in place, doctors prescribed on an individual basis.

• One of the GPs prescribing for clients undergoing alcohol detoxification treatment had not had any specific training in treatment for substance misuse.

• Some staff had not completed, or updated, all of their mandatory training.

• At our last inspection, we recommended that the provider ensured that staff supervision continued for all staff and was recorded. At this inspection staff reported that they had regular supervision. However, staff supervision records were not available to confirm the frequency, quality and content of staff supervision.

• Staff team meeting minutes for 2018 were not available. Team meetings did not include any standing agenda items concerning safeguarding, referrals, incidents or complaints.

• The governance systems and processes in the service were not effective and did not keep people safe. They were not sufficient to assess, monitor and improve the safety and quality of the service. Risks were not appropriately identified, monitored and minimised.

• Managers lacked a clear understanding of regulatory requirements. Auditing processes were not robust and concerns were not always identified and acted upon. There was no system to ensure that best practice and national guidance was consistently followed.

• The provider did not have a proper process to make robust assessments to meet the fit and proper persons regulation (FPPR).

However:

• At our last inspection, we identified that physical health monitoring equipment had not been regularly serviced and staff were not aware of their duty of candour. At this inspection, these matters had been resolved.

• People were cared for in a clean and comfortable environment and there were enough staff to meet the needs of the client group. Clients were supported and treated with dignity and respect and were involved as partners in their care. Clients were supported to understand and manage their care and treatment. The service offered family interventions and post discharge support groups.

• Clients were supported with their recovery journey. There was an extensive programme of individual and group activities that reflected patients’ individual needs and preferences. Clients had clear and detailed plans in place in the event of their unexpected exit from treatment.

• Clients were able to give feedback on the quality of their experience. This was reviewed by the management team to make improvements to the service.

• Staff felt respected, supported, valued and were positive about working for the provider and their team.

We informed the provider of our serious concerns during and immediately after this inspection. We sent a letter of intent (notice of CQC’s intention to take urgent action) to the provider about our concerns in relation to how assessment and treatment for clients’ detoxification was being managed. The provider decided to stop providing alcohol detoxification treatment to clients with a history of alcohol withdrawal seizures or delirium tremens. The provider also agreed not to admit any clients to No. 4 until the fire safety concerns had been addressed. The provider also sent an action plan to address our other immediate serious concerns. We have also taken other enforcement action concerning breaches of the Health and Social care Act 2008 (Regulated Activities) Regulations 2014. The details are found at the end of this report.

This was an unannounced focused inspection looking at progress the provider had made in addressing breaches found at our last inspection in May 2019. We did not rate the service as a result of this inspection.

We found areas of practice that require improvement.

• The service’s governance processes were not yet fully embedded. It was not clear where responsibility for assurance lay. For example, what level of meeting issues were discussed and actioned at.

• Some of the provider’s quality and safety data, for example data on staffing and admissions, was not shared or used locally and was only reviewed at the organisational level governance meeting held twice a year.
• The provider had not updated all policies and procedures to reflect changes in practice at the service. Some policies and procedures contradicted each other.
• The service did not yet have a fully comprehensive risk register that allowed staff to identify risk and manage it.
• The service did not have an updated fire risk assessment in place.

However:

• All clients undergoing detoxification had a comprehensive medical assessment.
• All clients’ medical assessments were consistent and standardised.
• All clients had a comprehensive risk assessment and risk management plan in place before starting treatment.
• The provider’s storage and administration of medicines had improved.
• The provider had installed new heat and fire detection systems and done remedial works to comply with the local fire service’s enforcement.
• The provider had taken action to ensure that environmental risks were appropriately identified, managed and mitigated.

We did not review the breaches identified under Regulation 5, Fit and Proper Persons and Regulation 18, Safe Staffing during this inspection. These breaches are carried forward in this inspection report and will be reviewed at our next inspection.

The service voluntarily agreed to continue not to admit any clients for alcohol detoxification who had a history of alcohol withdrawal seizures and delirium tremens until the service is comprehensively inspected.