The Care Quality Commission
  • Residential substance misuse service

Archived: St Stephens

Overall: Requires improvement read more about inspection ratings

52 St Stephens Road, Leicester, Leicestershire, LE2 1GG (01582) 730113

Provided and run by:
PCP (Clapham) Limited

Important: This service was previously registered at a different address - see old profile

All Inspections

4 - 5 November 2019

During a routine inspection

We rated PCP St Stephens as requires improvement because:

  • The facilities did not promote dignity, recovery and comfort of clients. There were no quiet areas in the accommodation, other than in client’s own bedrooms. There were not enough seats in the lounge area for all clients. There was no dining table and only three clients could sit at the small breakfast bar at any one time. The service had not provided adequate cooking facilities for clients who were expected to be self catering. Clients told us they had to wait a long time to cook their evening meal. The lighting in the property was dim, especially in bedrooms. The provider had not supplied any additional lighting to improve this.
  • Supervision had not always taken place as required by the provider’s policy. The provider’s policy stated that staff should receive supervision quarterly. We reviewed the files for five staff who worked at St Stephens and only one had received regular supervision. In addition, mangers did not formally supervise new starters they had been post for three months, the impact of this could be that new staff may encounter skills deficits or develop poor practice before they were formally picked up through the supervision process.
  • The provider only had one dose of Naloxone available at the house. Naloxone is an emergency medication used to reverse the effects of an opiate overdose. National guidance suggests that it is good practice to have at least two doses available.

However:

  • The service provided safe care. The accommodation where clients stayed during the evening and weekends was safe and clean. The service had enough staff to keep clients safe. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the clients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • We heard positive examples of staff providing exceptional care and support to clients. Staff treated clients with compassion and kindness and understood the individual needs of clients. They actively involved clients in decisions and care planning.

3 July to 4 July 2018

During an inspection looking at part of the service

We do not currently rate independent standalone substance misuse services.

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

  • The provider had not ensured a safe and clean environment for clients. The provider had not completed a ligature assessment for the property. There were no ligature cutters on the premises. The property was not clean on the day of our visit. The kitchen cupboards were dirty, we found a dirty chopping board, there was mould around the bath in the ground floor bathroom and a build-up of lime scale around some of the taps. Not all clients were aware of fire safety procedures.
  • The provider did not have effective infection control measures in place. There was only one mop in the property for cleaning kitchens, bathrooms and bodily spills. The provider had covered the worktop in a badly fitted laminate, the trim was coming away and tiles in the kitchen around plug sockets and switches had rough edges, which created areas which were difficult to keep clean. We found wooden utensils in the kitchen, these were visibly unclean.
  • Clients had no means of summoning help from their bedrooms. There was no procedure in place for the observation of clients undergoing detoxification at the property. Staff told us they would check on clients as and when they thought it necessary. This posed a risk that clients may not receive emergency care if they were to suffer side effects from the detoxification treatment, for example, seizures.
  • The stairs in the property were not safe. Two stair treads were loose and one carpet gripper was exposed. The carpet was loose in places. This posed a risk to clients tripping and falling whilst using the stairs.
  • Governance of the service was poor. The provider did not have monitoring systems in place to ensure staff followed processes or key performance indicators to monitor the performance of the team. For example, the provider did not know that the new cleaning schedules were not being followed, that there were maintenance issues at the property and some staff were not being supervised.
  • Recruitment procedures were not robust. Staff had been appointed to specialist roles with no previous experience or skills and one had not received an induction or training to enable them to fulfil the role.
  • Staff did not receive regular supervision. The provider’s policy stated that staff should receive supervision quarterly. We reviewed staff files of two staff who worked at St Stephen’s. Both staff had only received two supervisions in the last year.

However, we also found the following areas of good practice:

  • Clients were treated with kindness, dignity and respect. Clients reported that staff treated them well and respected their wishes. Staff were open and transparent and explained to clients when things went wrong. This was clear in community meeting minutes and client feedback records.
  • Staff completed detailed risk assessments and care plans for clients on admission to the service and updated these regularly.
  • Staff adhered to the principles of the Mental Capacity Act. There was evidence in care records that capacity had been assessed and consent to treatment had been gained. Clients signed a treatment contract on admission to the service.
  • Access and discharge to and from the service was well planned. Staff planned for early exit from treatment at the assessment stage including details of who should be contacted if a client relapsed or discharged themselves from treatment early.
  • Clients told us they felt comfortable to raise concerns in the weekly community meetings and that any concerns raised were responded to quickly. Clients were provided with information on how to complain on admission and could complain at community meetings, individual sessions or directly to the registered manager.
  • Staff reported that it was a supportive team; there were no reports of bullying or harassment. Staff spoken with told us they knew how to use the whistle-blowing process. Staff told us that morale was high and they gained a great deal of job satisfaction from supporting people with their recovery.