The Haynes Clinic Limited Also known as Chicksands

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We rated Well-led as Inadequate because the service did not set out a clear vision or strategy. Leaders did not ensure that risks were well managed in the service. The service did not have clear responsibilities, roles, systems of accountability or good governance structures in place to manage and deliver good quality care, treatment and support.

However, staff told us that leaders were present onsite and that they engaged with people. The service valued lived experience.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not set out a clear vision or strategy.

Leaders did not demonstrate a culture that was focused on learning and improvement. For example, we found that lessons learnt from incidents had not been effectively implemented.

However, staff told us that leaders were present onsite and that they engaged with people. People we spoke with confirmed this.

Staff and leaders said they felt supported and took pride in their work.

The service valued lived experience.

Leaders did not have the knowledge and experience to ensure the quality of clinical care and treatment was delivered safely and effectively. For example, leaders had completed audits of medicines administration records however they had not identified any of the concerns found during the inspection.

Leaders did not ensure that risks were well managed nor that learning from incidents was effectively embedded in the service. Leaders did not have good oversight of ongoing risks within the service. There was no risk register and no formal mechanism in place to record, assess or monitor risks. Lesson learnt from incidents were not fully effective, this meant we were not assured that future incidents could be prevented.

The service had a whistleblowing policy in place. Staff we spoke with told us they would speak to the manager if they had concerns and would feel comfortable to do so. However, we saw that when staff and people who used the service had raised concerns the service did not complete a full investigation into the concerns raised and as a result did not learn lessons from these. People raising concerns did not receive an apology or any actions to address their concerns.

The service did not have a whistleblowing champion in place.

People had opportunities to give feedback in community meetings. They were also asked to provide feedback on discharge from the service. Feedback from people currently using the service was positive about their care and treatment.

The service had an equality policy in place. Some staff members had lived experience of substance use and were representative of the people population. Staff were kept up to date with mandatory equality and diversity training.

Managers told us there had been no incidents of bullying or harassment amongst staff. However, there was no performance monitoring arrangements in place.

The service did not have clear responsibilities, roles, systems of accountability or good governance structures in place to manage and deliver good quality care, treatment and support. Managers did not ensure there were effective systems and processes in place to identify and record risk and therefore they did not have easy access to the best information about risk, performance and outcomes to act, identify themes or learn lessons.

The lack of governance systems and processes meant that the service did not always keep people safe. For example, actions taken following serious incidents were not effective to prevent future deaths occurring again such as the lack of action to replace wardrobe rails and the implementation of an observation policy that was not fit for purpose.

We reviewed examples of governance meeting minutes. There was not a clear framework of what must be included on the agenda to ensure that essential information, such as learning from incidents, audits and complaints, were routinely recorded, monitored or actioned.

The service did not have a risk register in place. This meant there was no oversight of ongoing risks within the service and no formal mechanism in place to record, assess or monitor risks.

Managers told us they undertook weekly audits of medication supplies and files and there was a monthly audit of patients discharged from the service. The service did not have a clear audit programme in place to cover essential information on the performance of the service and staff did not complete effective audits as the concerns we found had not been identified through audit processes. The service did not have any clinical oversight of medicines management and detoxification.

Human Resources (HR) processes were not robust. One staff member had a conviction recorded on their Disclosure and Barring Service (DBS) that had not had an associated risk assessment completed. The service was issued a requirement notice at the last inspection for all staff with convictions to have a risk assessment completed. The Disclosure and Barring Service helps employers make safer recruitment choices.

The service did have a contingency and emergencies planning policy in place in the event of major incidents or disruption to services.

Managers told us how they worked with partner external referral agencies such as Rehabs UK, Help 4 Addiction and Steps to Recovery by receiving the details of the people they had been assessing as suitable for treatment. The service then assessed them to confirm that they were suitable for treatment at the Haynes Clinic.

The service worked with a charity called Sikh Recovery Network.

However, the service did not routinely share information with providers of physical or mental health services such as GPs and community mental health teams. This meant that people physical and mental health needs were not always being fully supported during their stay at the Haynes clinic.

Whilst the service utilised the local pharmacy for prescriptions, supplies and depositing unused medications there was no arrangement in place with the local pharmacy to visit the clinic to support with medications audits and stock takes.

The provider gave examples of improvements following people’s feedback on the service. These included more team building groups, guided walks and gardening sessions.

Other examples of innovations and improvements included the introduction of music groups, groups held in the open air, enhanced aftercare package including follow up 1-2-1s having been made available, and a more streamlined booking process and a new confirmation email clarifying the admission process for people put in place.

However, lessons learnt following incidents were not always effectively actioned.