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Inspection Summary


Overall summary & rating

Updated 4 May 2017

We do not currently rate independent standalone substance misuse services.

We found the following areas of good practice:

  • The service had a well-equipped, clean and tidy clinic room.

  • Staff monitored and recorded the room temperature daily.

  • The service had access to naloxone (used to reverse the effects of opioids) and a defibrillator. Staff carried out weekly audits of emergency equipment.

  • Overall, 100% of staff had completed mandatory training.

  • All clients had an initial risk assessment and all risk assessments had been updated within the past month. Risk assessments were comprehensive and included what process to follow for a client who unexpectedly exits treatment.

  • The service had robust processes in place for medicines management and administering medication.

  • Staff we spoke with were aware of what constituted an incident and how to report an incident. Staff received feedback from incidents and were able to tell us about changes and learning from incidents within the service.

  • We observed staff interacting with clients in a kind, considerate and caring manner.

  • Clients we spoke with told us staff were interested in their wellbeing and that staff were respectful, polite and compassionate. Clients said they felt safe while using the service, and were happy with the treatment they were receiving.

  • All clients we spoke with said they were involved in and offered a copy of their treatment plan. Staff reviewed and updated individual treatment plans weekly. Treatment plans viewed were holistic, personalised, recovery orientated and looked at a client’s strength areas.

  • Families could be involved in treatment with client agreement. The service facilitated monthly family meetings. Family members were asked for feedback about care and treatment.

  • Staff completed comprehensive assessments on the day of admission. The doctor completed medical assessments at the point of a client’s admission for treatment; this included a physical health examination to ensure suitability for detox. The nurse undertook physical health checks including blood pressure, breathalysing, and urine testing.

  • Staff were inducted to the service appropriately. All staff working within PCP Luton were regularly supervised and all eligible staff had a recent appraisal completed. Staff had access to bi-weekly team meetings, monthly group supervision and daily handovers. Staff had access to specialist training for their role.

  • The service rarely cancelled appointments or groups due staff shortages or sickness.

  • Facilities were available at the treatment centre so that clients could make a hot or cold drink when they wanted to. Lunch was ordered and delivered from a local café.

  • The service received 80 compliments in the 12 months prior to inspection.

  • Clients knew how to complain; in addition information about making a complaint was displayed in the seating are of the treatment centre, along with a comments box.

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

  • The blood pressure machine and alcometer (

    used to measure level of alcohol in breath)

    had not been calibrated.

  • The service had not completed a ligature audit for the treatment centre.

Inspection areas

Safe

Updated 4 May 2017

We do not currently rate standalone substance misuse services.

We found the following areas of good practice:

  • The service had a well-equipped, clean and tidy clinic room.

  • Staff were recording and monitoring room temperature daily.

  • The service had access to naloxone (used to reverse the effects of opioids) and a defibrillator. Staff carried out weekly audits of emergency equipment.

  • The furnishings in the treatment centre were clean, well maintained and had recently been decorated to a high standard.

  • All communal areas of the treatment centre were clean and well maintained.

  • Overall, 100% of staff had completed mandatory training, 100% of staff were trained in safeguarding adults and children and safeguarding vulnerable adults.

  • All 11 clients had an initial risk assessment and all risk assessments had been updated within the past month. Risk assessments were comprehensive and included what process to follow for a client who unexpectedly exits treatment.

  • The service had robust processes in place for medicines management and administering medication.

  • Staff we spoke with were aware of what constituted an incident and how to report an incident. Staff received feedback from incidents and were able to tell us about changes and learning from incidents within the service.

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

  • The blood pressure machine and alcometer (used to measure level of alcohol in breath) had not been calibrated.

Effective

Updated 4 May 2017

We do not currently rate standalone substance misuse services.

We found the following

areas of good practice:

  • Staff completed comprehensive assessments on the day of admission. The doctor completed medical assessments at the point of a client’s admission for treatment; this included a physical health examination to ensure suitability for detox.

  • Staff reviewed and updated individual treatment plans weekly. Treatment plans viewed were holistic, personalised, recovery orientated and looked at a client’s strength areas.

  • The service offered a variety of daily activities and therapies

  • Staff were inducted to the service appropriately. All staff working within PCP Luton were regularly supervised and all eligible staff had a recent appraisal completed. Staff had access to bi-weekly team meetings, monthly group supervision and daily handovers.

  • Staff had access to specialist training for their role.

  • Overall, 100% of staff had completed training in the Mental Capacity Act.

  • Staff invited prospective clients to visit the service before accepting a place.

  • Staff supported clients to formulate their own leaving plans, including unexpected exit from treatment.

Caring

Updated 4 May 2017

We do not currently rate standalone substance misuse services.

We found the following

areas of good practice:

  • We observed staff interacting with clients in a kind, considerate and caring manner.

  • Clients we spoke with told us staff were interested in their wellbeing and that staff were respectful, polite and compassionate. Clients said they felt safe while using the service, and were happy with the treatment they were receiving.

  • Clients told us there was always enough staff to offer additional support.

  • Staff gave all clients a welcome pack on admission.

  • All clients we spoke with said they were involved in and offered a copy of their treatment plan.

  • Families could be involved in treatment with client agreement. Clients told us the service facilitated monthly family meetings. Family members were asked for feedback about care and treatment.

  • Clients were able to give feedback on the service by using the comments box or during weekly community meetings.

Responsive

Updated 4 May 2017

We do not currently rate standalone substance misuse services.

We found the following

areas of good practice:

  • A pre-admission assessment was completed with clients to assess suitability prior to them being accepted to the service. The service had a clear exclusion criterion in place. The registered manager and the doctor assessed all referrals on a case by case basis.

  • The service rarely cancelled appointments or groups due staff shortages or sickness.

  • PCP Luton treatment centre had a range of rooms available to support treatment.

  • Facilities were available at the treatment centre so that clients could make a hot or cold drink when they wanted to. Lunch was ordered and delivered from a local café.

  • The service received 80 compliments in the 12 months prior to inspection.

  • Clients knew how to complain; in addition information about making a complaint was displayed in the seating are of the treatment centre, along with a comments box.

Well-led

Updated 4 May 2017

We do not currently rate standalone substance misuse services.

We found the following

areas of good practice:

  • The service had a robust recruitment process; we looked at seven staff and volunteer personnel files. Overall, 100% of active volunteers and of substance misuse staff had a current disclosure and barring service (DBS) check and all staff had two references located within their personnel files.

  • Overall, 100% of staff had completed mandatory training, 100% of staff had regular supervision and all eligible staff had an up to date appraisal.

  • All employed staff were involved in completing audits.

  • Between December 2015 and December 2016 one member of staff left the service. Between September 2016 and February 2017 there were no unauthorised absences or sickness days taken by staff.

  • Staff told us they knew the whistle-blowing process and felt able to raise concerns without fear of victimisation.

  • None of the staff or managers we spoke with raised any concerns regarding bullying or harassment.

  • Staff morale at the service was high. Staff told us that they felt valued and rewarded for the job they do.

  • We saw evidence of recruiting from within the service.

Checks on specific services

Substance misuse services

Updated 4 January 2016

Residential substance misuse services

Updated 4 May 2017

inspected but not rated

Other CQC inspections of services

Community & mental health inspection reports for Luton can be found at PCP (Luton) Limited.