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New Writtle Street Requires improvement Also known as PCP Luton - 53 New Writtle Street

Inspection Summary


Overall summary & rating

Requires improvement

Updated 18 December 2018

We rated New Writtle Street as requires improvement because:

  • The provider was unable to demonstrate they had considered the risks posed by mixed sex accommodation. Female clients were situated in bedrooms next to male clients. Bedrooms did not have ensuite bathrooms, which meant that women would have to walk past men’s bedrooms to get to the bathroom. The provider had not fitted locks on the bedroom doors which posed a risk others could go into the rooms. This posed a risk to clients’ safety, privacy, and dignity. The provider had not completed a risk assessment of mixed sex accommodation, so were unaware of potential risks, or how these should be managed. The service was not accessible for people with disabilities. The service did not use key performance indicators and there were no auditing processes in place to monitor staff compliance.
  • The door to the bedrooms did not have a lock. The provider did not have governance systems in place to monitor mandatory training, supervision, and appraisals for staff. The provider could not provide information on compliance rates.

However:

  • Staff completed risk assessments of clients. If staff considered clients a risk of self-harm or suicide, staff would increase observation levels to reduce any risk identified. The provider covered shifts with sufficient staff of the right grades and experience. There was adequate medical cover for the service. A doctor was available on call should the staff require medical advice. If there was a medical emergency staff called the emergency services. Staff received safeguarding training and knew how to raise safeguarding alerts. Staff knew how to report incidents and what to report. Staff knew how to use the provider’s whistleblowing processes. Staff received feedback from the investigation of incidents during team meetings. Staff were open and transparent and explained to clients when things went wrong.
  • Staff had good staff morale throughout the service. Staff told us they felt happy in their role and that senior colleagues supported them.
  • All areas of the service were clean and tidy. The provider recently redecorated the service and installed new furniture. The service employed a cleaner who attended once a week. The service adhered to infection control principles. There were hand-washing facilities and disinfectant gel was located throughout the service. The service had policies and procedures in place for the use of observations and searching clients. The service had beds available when clients needed them.

  • The service did not admit clients who were detained under the Mental Health Act. Clients were aware of the right to leave at any time. Clients received a comprehensive assessment following admission which covered substance misuse history as well as all other needs. Clients received a physical examination upon admission. Clients told us staff were very kind and caring and treated them with dignity and respect. Clients told us that staff were very responsive to their needs and very supportive. Staff showed clients around the service on arrival and provided a welcome pack containing information about the service. Clients gave feedback on the service they received. Clients attended community meetings in which they could give their input. Clients made private phone calls in bedrooms, and had access to outside space. Clients could personalise their rooms, and each room had a small safe and a lockable drawer to keep valuables secure.
Inspection areas

Safe

Requires improvement

Updated 18 December 2018

We rated safe as requires improvement because

:

  • The provider was unable to demonstrate they had considered the risks posed by mixed sex accommodation. The provider had not completed a risk assessment of mixed sex accommodation, so were unaware of potential risks.

  • The provider gave staff feedback from incidents which were often contradictory in nature, stating that the incident could not be avoided, but also giving suggestions as to how the incident could be mitigated.

However,

  • The provider had estimated the number of staff required. The service had recently increased staffing at night to one waking staff and one sleep in staff. The provider increased staffing levels following an incident in order to maintain clients’ safety.
  • Staff completed risk assessments of each client upon admission. We reviewed all clients’ care records.
  • All areas of the service were clean and tidy. The provider had recently redecorated the service and installed new furniture. The service employed a cleaner who attended once a week to keep premises clean and tidy.

Effective

Good

Updated 18 December 2018

We rated effective as good because:

  • Clients received a comprehensive assessment following admission. We reviewed the care records for the three clients and all had received an assessment from the doctor and the nurse upon admission.
  • Staff were supervised and appraised and had access to regular team meetings. We reviewed staff files and saw evidence staff were receiving supervision and appraisals in line with the provider’s policy.
  • Clients had access to physical healthcare, including access to specialists when needed. We saw evidence in care records that showed that staff supported clients to access dentists, opticians, and hospital appointments when needed.

Caring

Good

Updated 18 December 2018

We rated caring as good because:

  • We spoke to clients who told us that staff were very kind and caring and treated them with dignity and respect. Clients told us that staff were very responsive to their needs and very supportive.
  • The admission process orientated clients to the service. Clients told us that when they arrived, staff showed them around the service and they were given a welcome pack.

  • Clients could give feedback on the service they received. Clients attended community meetings in which they could give their input.

Responsive

Good

Updated 18 December 2018

We rated responsive as good because:

  • The service had beds available when people needed them. Staff assessed clients within 24 hours of receiving the referral.
  • The service had rooms and equipment to support treatment and care within the accommodation. The service provided all equipment to enable clients to maintain their activities of daily living.
  • Clients were able to personalise their bedrooms. We saw evidence that clients had bought in personal items such as photographs and personalised bedding.
  • Clients knew how to make complaints. Staff provided clients with information on how to complaint upon admission as part of the welcome pack.

Well-led

Requires improvement

Updated 18 December 2018

We rated well-led as requires improvement because:

  • The provider did not have a documented vision and values statement, either centrally or at a service level.
  • The service did not have systems in place to monitor mandatory training, supervision, and appraisals.
  • The service did not use key performance indicators and there were no auditing processes in place to monitor staff compliance.

We found the following areas of good practice:

  • The service covered shifts with sufficient staff of the right grades and experience. We reviewed the duty rotas for the three months prior to inspection and saw that all shifts were covered appropriately.
  • There was good staff morale throughout the service. Staff told us they felt happy in their role and that senior colleagues supported them.
  • Staff were open and transparent and explained to clients when things went wrong. We saw evidence in the complaint records where staff had given feedback to clients following a medication error.
Checks on specific services

Substance misuse services

Requires improvement

Updated 18 December 2018