Archived: SASS-Residential - Steade Road

We found the following areas of good practice:

• The provider had taken action to address the issues that we identified at our last inspection.

• The provider had implemented a form to record clients’ consent to sharing information with the National Drug Treatment Monitoring Service. We found this form was being used in care and treatment records when clients were consenting.

• The provider had implemented a new risk assessment and risk management plan tool and all the clients’ records we reviewed contained a risk assessment and risk management plan. Staff involved clients in the development and review of these regularly.

• The provider had made changes to care planning processes. Staff used a new care plan tool which was holistic and recovery orientated. Staff involved clients in developing and reviewing their care plans. Staff measured clients’ outcomes and progress through their treatment using the changes in care plan scoring.

• Staff had a working knowledge of the Mental Capacity Act.

• Staff knew how to report incidents and understood the provider’s incident reporting policy.

• Staff encouraged clients to resolve issues with other clients informally. Clients understood they could submit complaints and how to do this. Staff understood the provider’s complaints policy.

However, we also found the following issue that the service provider needs to improve:

• Where clients did not provide their consent to share information with the National Drug Treatment Monitoring Service, staff did not place a record in the clients file. This resulted in a blank consent to sharing information form in the records.

We do not currently rate substance misuse services.

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

• Staff did not identify or manage risk effectively. Staff did not record the risks in sufficient detail or review clients’ risk assessments regularly. Clients did not have a risk management plan. This meant staff relied on verbal information from discussions with clients and information recorded in the handover diary.

• Clients’ care plans varied in content. Three of the four care plans we looked at were incomplete. The care plans did not have clear goals or outline the recovery process. This meant there was no clear indication that the client was involved in constructing their care plan or agreed with it. Clients could have a copy of their care plan if they requested it.

• Staff did not have a clear understanding of the Mental Capacity Act and its application to clients using the service.

• The clients’ induction pack provided clear information on confidentiality and sharing of information. However, staff did not ask clients for consent to share information with the National Drug Treatment Monitoring System (NDTMS).

• While there was clear learning from serious incidents, staff did not appear to follow the governance structure for reporting all incidents. Staff dealt with some incidents informally and did not record them according to policy. This meant they could not identify trends.

• Staff dealt with informal complaints during the morning ‘feelings’ meeting. However, they did not document what the complaint was about or how it was resolved.

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

• The environment was homely and welcoming, with empathic and respectful staff.

• Clients were involved in decisions about their care and the service. They regulated their own code of conduct and agreed house rules with other clients.

• Staff tried to meet the diverse needs of clients and made arrangements or adapted rooms to meet individual needs.

• Staff had regular supervision and ongoing appraisals of their work performance from their manager, giving them the support and professional development needed to carry out their duties.

• Clients received care and treatment underpinned by best practice, and had access to psychosocial therapies, group work sessions and individual one to one sessions with a counsellor.

• Discharge planning included an aftercare package to support clients for up to five years following rehabilitation.