Nest Healthcare

• The service did not provide safe care. The service did not have a full ligature risk assessment in place.

• The mandatory training programme was not comprehensive and did not meet the needs of clients and staff.

• The service did not assess and manage risk well. Staff did not complete thorough risk assessments for each client on admission. Risk assessments were not regularly updated. Staff did not assess risks including the risk of early exit from treatment and did not complete risk management plans.

• The service did not use information from other agencies to support client’s treatment. Information from GP’s and others was not used as part of the decision-making process to admit service users or to manage any ongoing risks.

• Audit processes were not in place to ensure that observations were being carried out in line with the providers policy. Staff did not take part in regular audits, benchmarking, and quality improvement initiatives to evaluate the effectiveness of the service they provided.

• Staff did not follow systems and processes to prescribe and administer medicines safely. Staff did not review each client’s medicines regularly or provide advice to clients about their medicines. Staff did not complete medicines records accurately. Staff did not store and manage all medicines and prescribing documents safely. National practice was not followed to check clients had the correct medicines when they were admitted. Staff did not recognise and report medicines incidents and there was no learning taking place to improve practice.

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

• Incidents had not been reviewed or thoroughly investigated by competent staff. Incidents and learning from incidents were not discussed at multidisciplinary team meetings or clinical governance meetings.

• Staff did not develop a comprehensive recovery plan for each client that met their substance misuse, mental health, and physical health needs.

• Staff did not use recognised rating scales to assess and record the severity of clients' conditions and care and treatment outcomes.

• The service did not have a clear admission and exclusion criteria. Pre-admission assessments lacked specific detail. Information was missing prior to admission that would have supported risk assessment and recovery planning.

• Leaders failed to implement safe systems and processes to provide safe and good quality care to clients accessing the service.

• The governance system was not structured. Individual elements, such as audits, training and learning from incidents were not collated into overarching systems so that performance, themes, and trends could be monitored and proactively addressed.

However:

• The service was clean, well-furnished, and fit for purpose.

• The service had enough staff to provide care for clients.

• Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity.

Action the service MUST take is necessary to comply with its legal obligations. Action a trust SHOULD take is because it was not doing something required by a regulation, but it would be disproportionate to find a breach of the regulation overall, to prevent it failing to comply with legal requirements in future, or to improve services.

Action the service MUST take to improve:

• The service must ensure staff develop a comprehensive recovery plan for each client that meets their substance misuse, mental health, and physical health needs. (Reg 9)

• The service must ensure thorough risk assessments are completed for each client on admission, are updated regularly and include the risk of early exit from treatment and risk management plans. (Reg 12)

• The service must ensure information from the clients GP is used as part of the decision-making process to admit clients. (Reg 12)

• The service must ensure staff follow systems and processes to prescribe and administer medicines safely. (Reg 12)

• The provider must ensure that equipment is appropriately maintained and calibrated. (Reg 12)

• The service must ensure staff review each client’s medicines regularly. (Reg 12)

• The service must ensure staff store and manage all medicines and prescribing documents safely. (Reg 12)

• The service must ensure staff report medicines incidents. (Reg 12)

• The service must ensure incidents are reviewed, investigated and learning is identified. (Reg 12)

• The service must ensure that recognised rating scales are used to assess and record the severity of clients' conditions and care and treatment outcomes. (Reg 12)

• The service must ensure that comprehensive pre-admission assessments are completed. (Reg 12)

• The service must have naloxone in stock to reverse the effects of an opiate overdose. (Reg 12)

• The service must ensure that they have clear admissions criteria in place. (Reg 17)

• The service must ensure that governance systems and process including audits are in place. (Reg 17)

• The service must ensure it has a comprehensive ligature risk assessment and ligature risk management plan in place. (Reg 17)

• The service must ensure its mandatory training programme is comprehensive and meets needs of clients and staff. (Reg 18)