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Archived: The John Kitchen Centre Inadequate

Inspection Summary

Overall summary & rating


Updated 13 March 2019

This was an unannounced, comprehensive inspection. We rated The John Kitchen Centre as inadequate. Immediately following our inspection, we took enforcement action to stop the provider from accepting new clients for detoxification treatment with immediate effect. We are also taking enforcement action where we will be proposing the cancellation of the registration of this location for the provider. This would mean that the provider will no longer be able to operate this service.

Overall, we rated the service as inadequate because:

  • CQC previously inspected The John Kitchen Centre in August 2016. Following the August 2016 inspection, we told the provider that it must act to improve the service. During this inspection we found that the actions needed to improve the service had not been taken. This included improving the safety of medication management, ensuring that appropriately detailed records relating to risk management and the delivery of care were maintained for each client, that the necessary pre-employment checks were completed for all staff and that an appropriate governance structure and auditing system was put in place.

  • Staff did not manage the care of people undergoing detoxification safely. The service did not identify and exclude clients whose needs could not safely be met by the service. Staff did not complete a comprehensive assessment of clients’ needs, including their needs for physical healthcare or the extent and nature of their drug or alcohol dependence, before clients commenced detoxification treatment.

  • Staff did not undertake ongoing monitoring of clients’ withdrawal symptoms and physical healthcare status as required by the provider’s detoxification protocols. This posed a risk that a physical deterioration in clients undergoing detoxification treatment would go undetected.

  • The service did not have appropriate arrangements in place to respond to emergencies or access medical advice out-of-hours.

  • Staff did not provide clients with sufficient information about treatment options, or the risks associated with their treatment, nor did they document their consent to treatment. Staff did not alert clients to the risks they faced if they exited treatment early. For example, the risk of loss of opioid tolerance - leading to risk of overdose - and the risk of seizures.

  • Staff did not assess the risks to individual clients adequately on admission nor did they put plans  in place to safely manage these risks. The service did not assess clients’ mental health to determine whether their drug or alcohol misuse was masking an underlying condition.

  • The provider did not have governance processes in place to provide assurance about the quality and safety of the service, and to alert the provider to improvements that needed to be made. Managers did not audit the management of medicines, the quality and completeness of clinical records or staff employment files. Staff did not manage medications safely. They did not ensure that medications were stored safely, they did not undertake risk assessment of clients who administered their own medication and the provider had no system to enable staff to check if medications were missing. Staff did not manage risk posed by potential ligature anchor points to protect clients who were vulnerable to suicide or self-harm. The service did not consider the gender mix or location of clients’ bedrooms, meaning that the provider was not doing all that was practicable to mitigate the risk of sexual safety incidents occurring.

  • The provider did not complete the necessary pre-employment checks to provide assurance that volunteers and staff were suitable to work at the service.

  • Staff did not work within their qualification or competency level and the provider did not assure itself that staff and volunteers were competent to carry aspects of their roles including managing medications.

  • The service had not developed a culture of learning from incidents. Incidents were not discussed routinely by staff and staff did not act to identify learning from incidents to make improvements to the service.

  • The provider did not have sufficient information available to staff about how to make a safeguarding referral.

  • There was no system to ensure the provider’s policies and procedures were regularly reviewed and reflected up-to-date professional guidance. Policies were not dated.

Inspection areas



Updated 13 March 2019

We rated safe as Inadequate because:

  • During our last inspection in August 2016 we identified that the provider did not ensure there were appropriately detailed records available in relation to risk management and the planning and delivery of treatment and care for clients. During this inspection we found that staff still did not assess, monitor or manage risks to people who used the service. Client risk assessments were not detailed enough, completed in a timely manner or updated when risks changed. Risks that were identified in risk assessments did not feed into risk management plans and the service could not demonstrate how they were working to manage or mitigate the individual client risks to keep them safe.

  • Clients undergoing detoxification treatment were not monitored adequately. One volunteer slept at the service at night; including when clients were undergoing detoxification treatment. Clients undergoing detoxification treatment were provided with alarms but these required manual activation; which might not be possible if the client had a seizure. There was no procedure in place to routinely observe clients undergoing detoxification treatment through the night.

  • Staff and volunteers did not have the skills and competency to safely meet the needs of clients. Managers could not easily monitor whether staff or volunteers had attended the necessary training to safely meet the needs of clients.

  • The information needed to plan and deliver effective care, treatment and support was not readily available to staff. Staff working at the service did not have access to important clinical information about the clients’ healthcare needs that had been documented by the service’s contracted doctor. This included the record of the medical assessment; which was held at the GP surgery. This meant that staff did not have access to all the necessary clinical information to safely meet client’s individual needs and prevent or minimise potential harm to clients.

  • Clients were not adequately informed of the risks associated with detoxification treatment before they consented to this treatment. Clients did not have plans in place about how to safely manage themselves if they left the service during their detoxification treatment, to mitigate risks including overdose or seizures.

  • During our last inspection in August 2016, we identified that the management and administration of medication needed to be reviewed to ensure arrangements were as safe as possible for clients and to minimise the risk of errors by staff. During this inspection, we identified that the procedure for administration of medications was still unsafe. Clients were not risk-assessed to administer their own medications. Volunteers who supervised administration of medications were potentially vulnerable to misusing medications and were often distracted when observing medication administration. Staff did not accurately record medication administration so the provider would not know if medication was missing. Staff did not store medications safely. The provider did not have a system to monitor the temperature of the rooms and fridges in which medications were stored and so could not guarantee they had been stored appropriately and were safe to administer.

  • The service did not have the necessary resources to respond to physical health emergencies. The likelihood of these emergencies occurring was heightened by the fact that some clients underwent detoxification treatment from opiates or alcohol at the service. Medical cover was not sufficient and staff relied on an out-of-hours GP telephone number or the emergency services for emergency support out-of-hours. The service did not have emergency equipment or emergency drugs on-site that could help preserve life in an emergency.

  • Staff did not consider whether the premises were safe when identifying whether client’s’ individual needs could be safely managed by the service. Routine environmental observations and a ligature risk assessment were not in place. There were no risk management plans for clients who were identified as being at heightened risk of suicide or self-harm to protect them from environmental risks. The service did not consider the gender mix or location of clients’ bedrooms, meaning staff were not doing all that was practicable to minimise the likelihood of sexual safety incidents occurring.

  • Staff did not have access to the necessary information to inform them how to make a safeguarding referral. There was insufficient attention to safeguarding children and adults in the provider’s adult abuse policy. Although the registered manager knew how to make a safeguarding referral, there was no information to other staff members informing them about how to do this if the registered manager was absent.

  • During the last inspection in August 2016, we identified that the provider did not ensure pre-employment checks, including suitable references and written explanations of gaps in employment history, were completed for all staff. During this inspection the service still had not completed the required pre-employment checks for staff and volunteers. The provider had not satisfied itself that individuals with criminal backgrounds were safe to work with vulnerable people.

  • Staff did not consider what could be learned from incidents that occurred and did not routinely discuss recent incidents. This increased the likelihood that similar incidents would re-occur in future.



Updated 13 March 2019

We rated effective as inadequate because:

  • Clients’ needs were not robustly assessed at the point of referral or when their detoxification treatment commenced. The contracted doctor relied on limited information to assess whether individual clients needs could be suitably managed by the service. They did not always wait for information from the client’s GP. Physical examinations and blood tests were not routinely completed before commencing detoxification treatment and the prescribing doctor relied on clients to disclose information relating to physical and mental health conditions.

  • Managers were not able to assure themselves that staff and volunteers had the necessary skills and experience to deliver good quality, safe care. Clients received care out-of-hours from volunteers who did not have the skills or experience to deliver effective care.

  • People’s care and treatment did not reflect current evidence-based guidance. Physical health monitoring did not take place for clients undergoing detoxification from opiates or alcohol according to the providers detoxification protocols. This presented a risk that physical health emergencies would not be detected and acted on promptly.

  • Staff did not assess the severity of dependence effectively before they started clients on detoxification treatment. This meant that the contracted doctor had limited information to determine whether the provider’s standard detoxification regimes were appropriate for individual clients. Withdrawal scales, which are ordinarily used to monitor symptoms of withdrawal as detoxification treatment progresses, were used during the assessment process rather than specific dependence measures.

  • Withdrawal scales were not subsequently used according to the provider’s detoxification protocols throughout the duration of detoxification treatment. This meant that staff were not closely monitoring the severity of withdrawal symptoms to determine whether the prescribed detoxification regime was appropriate for the individual. This also meant that staff would not be in a position to identify and take prompt action to avoid severe withdrawal symptoms such as seizures.

  • People who misuse drugs and alcohol often also have an underlying mental health condition. Despite this, the provider was not proactive in assessing clients’ cognitive and mental health state during and post-detoxification treatment. This meant that clients’ who had been using alcohol or drugs to mask an underlying mental health condition would continue to live with the condition undetected.

  • Staff did not obtain consent to treatment, or did not record this clearly, in line with the Mental Capacity Act 2005.



Updated 13 March 2019

We rated caring as good because:

  • Clients were positive about the relationships they had developed with staff. They reported that staff supported them with their recovery and they felt that their time spent with the service had been beneficial.

  • Clients were allocated a key worker and they worked to support clients to find appropriate move-on accommodation at the end of their treatment programme.

  • Former clients were encouraged to keep in touch with the service and build on their skills by volunteering.


  • Some clients reported there was not enough structured activity to keep them occupied at weekends.

  • Although staff involved people’s families and carers in their care when requested, the service did not provide direct family support through interventions or mutual support groups for carers.



Updated 13 March 2019

We rated responsive as good because:

  • The service contained plenty of large, bright spaces that promoted comfort and dignity.

  • Staff supported clients’ religious needs and dietary requirements.

  • The service had developed working relationships with local mutual aid groups, and encouraged clients to attend these. This included an LGBT mutual aid group for clients who would benefit from sharing experiences with members of their community.

  • Clients knew how to complain and were familiarised with the provider’s complaints procedures when they commenced treatment.


  • The service did not have clear criteria about who should be excluded from the service because their needs could not be met safely. Exclusion criteria were not clearly set out in one place and staff were inconsistent about which criteria they could or could not safely manage at the service.

  • Clients with known mental health conditions or histories of poor mental health had not been subject to review to establish whether or not the service could safely meet their needs. The need for this process was detailed on the provider’s referral form.



Updated 13 March 2019

We rated well led as inadequate because:

  • The service did not have leaders with the right skills and abilities to run a service providing high-quality sustainable care. Leaders did not have the necessary knowledge or capability to lead a detoxification service safely and effectively. Leaders did not identify or understand the risks associated with the treatment they were delivering.

  • The service had not taken action to meet the requirements identified during our last inspection in August 2016. These related to safe management of medications, developing governance systems to assure the quality and safety of the service, and operating effective recruitment procedures.

  • During our last inspection in August 2016, we identified that the provider did not have an appropriate governance structure in place to ensure all appropriate procedures were in place and put into practice. We also identified that the provider did not undertake audits of the quality of the service in relation to the relevant care standards and ensure improvements were made as necessary. During this inspection, we concluded that the governance arrangements and their purpose were still unclear. The provider did not have appropriate systems to assess the quality and safety of the care and treatment they were delivering. There were no audits in relation to medication management, or adherence to best practice in relation to alcohol or opiate detoxification treatment.

  • The provider did not capture the learning from incidents on its incident reporting system or ensure that incident reports fed into the provider’s governance structure. This meant that incidents were not discussed routinely at meetings and changes made to the service as necessary to prevent similar incidents re-occurring.

  • The provider’s policies and procedures were not dated. There was no plan for routine reviews of policies and procedures which meant that the service could not assure itself that they were in line with up-to-date professional guidance.

  • The provider did not have robust systems in place to ensure staff were competent to fulfil their roles. Information about training compliance could not easily be obtained, and there were no clear plans around how shortfalls in mandatory training compliance were being addressed. Staff competence to manage the medicines administration process was not monitored.

  • The service did not have a service-level risk register or business continuity plan. Risks to the service had not been identified and there was no plan to initiate if the delivery of the service was compromised in any way to ensure the service could continue to operate.


  • Staff and volunteers enjoyed working at the service and felt appreciated for their contribution.
Checks on specific services

Substance misuse services


Updated 13 March 2019