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Archived: The John Kitchen Centre Inadequate


Inspection carried out on 5, 6 and 20 November 2018

During a routine inspection

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 carried out on 17 August, 6 September, 3 October 2016

During a routine inspection

We do not currently rate independent standalone substance misuse services.

We found the following issues that the service user needs to improve:

  • Clients were at risk because the service did not manage medicines safely. Staff removed prescribed tablets of medicine from their original packaging and placed the tablets in a dossette box each week. In the case of one medicine, this was contrary to the manufacturer’s advice and may have made the medicine ineffective. In addition, staff had not checked clients’ health needs and ensured that it was safe to assist clients to take over-the-counter painkillers such as paracetamol. It was important that they made these checks because some clients may have had health conditions which placed them at risk when they took such pain-killers.

  • Governance arrangements in the service required improvement. During the inspection, we confirmed that the service worked in collaboration with a contracted doctor to ensure that admissions for detoxification were safe. However, there were no written procedures about admission criteria for detoxification. Records were not kept in the service of the decisions made by the contracted doctor and staff in regard to the care and treatment of clients. Staff records in relation to the care and treatment offered to clients in the service were very brief and lacked detail on the progress of clients at the service. We could not be certain that staff had fully identified and met clients’ needs. Recruitment records did not explain how decisions had been made in relation to the recruitment of staff and volunteers. The provider had not ensured that there were effective systems in place to monitor the management of medicines in the service, the quality of procedures and record-keeping, or the competence of staff to undertake their work roles.

We found the following areas of good practice:

  • The service was person-centred in its approach to the admission of clients to the service. Staff invited prospective clients to the service to explain to them how the service was provided and fully involved them in the admissions process.

  • The service worked well with partner organisations to provide short-term accommodation and support to clients who were previously homeless.Clients were assisted to move on from the service to appropriate long-term accommodation.

  • The service was pleasantly furnished and well maintained. Clients received healthy meals and were encouraged to participate in activities to help them recover from their substance misuse issues. Clients said that staff were caring and kind and that the service promoted their recovery.

Inspection carried out on 24 September 2013

During a routine inspection

There were 20 men and two women staying at the centre when we visited. The centre had recently started accepting referrals for women.

People usually stayed at the centre for 12 weeks. We spoke with people who had recently arrived at the centre and those who were nearing the end of their stay there. They said they were made welcome by the staff and the people using the service. One of them said the staff were �brilliant� and that they could talk to them at any time. They said they were learning to talk about their emotions and to address the roots of their addiction.

The centre liaised closely with other services so that people could continue their rehabilitation after they left the centre. A GP attended the centre and we saw that people had access to the health services they needed.

The centre felt comfortable and relaxed. The premises were well maintained and there were checks to make sure the building was safe.

There were appropriate systems in place to recruit staff. Staff contributed to improvements to the service. The quality of the service was monitored.

Inspection carried out on 10 January 2013

During a routine inspection

There were 20 men staying at the centre when we visited. We spoke to five of them.

The people told us staff explained the service to them. One person who did not speak English as a first language said the workers noticed when he didn�t understand something, for example in a group session, and explained things to him individually.

We observed people using the service interacting with each and other and with members of staff. Someone who had recently arrived at the centre said �they�ve made me feel at home�.

People using the service were supported to withdraw from substance use safely. One of them said �I feel I have a new life�. Another man said �I feel I am changing. I�m very happy�.

Appropriate arrangements were in place in relation to the storage, recording and administration of medicines.

People who use the service told us that staff were there when they needed them and that their key worker supported them at a pace that was right for them. We found evidence that staff undertook regular training and were encouraged to undertake professional development. Staff said they were well supported by the manager, although not everyone had regular formal one to one meetings.

People were asked their views about the service and staff told us they were able to contribute to improvements. There were systems in place for monitoring the safety and quality of the service.