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Inspection carried out on 03/04 April 2019

During a routine inspection

Following this inspection, we have removed this provider from special measures.

Our rating of this service improved. We rated it as good because:

  • The services had undergone significant improvement since our last inspection in September 2018.

  • 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 cared for in a residential detoxification and substance misuse service. Treatment was clearly aligned with national best practice guidance and staff used clinical audit to evaluate the quality of care they provided.
  • Clients had access to the full range of specialists required to meet their needs. Staff worked well together as a multi-disciplinary team and with those outside the service who would have a role in providing aftercare. The provider had improved the mandatory training programme it offered to staff to support them to provide good quality and safe care. Managers ensured that staff received training, supervision and appraisal.
  • Staff completed detailed and meaningful risk assessments and risk management plans with clients following their initial assessment. The provider had reviewed and minimised the use of restrictive practices. They managed medicines safely and followed good practice with respect to safeguarding. The treatment and accommodation environments were safe and clean.

  • Staff treated clients with compassion and kindness, respected their privacy and dignity and understood the individual needs of clients. The provider had reviewed records and leaflets to ensure use of appropriate language.
  • Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed other than for a clinical reason. The service offered free aftercare, allowing clients to access groups and support at the centre following discharge, and used a clear protocol for managing clients unplanned exits from treatment.
  • Staff understood and discharged their roles and responsibilities under the Mental Capacity Act 2005. The provider had updated its policies, processes and training requirements to promote compliance with the requirements of the Mental Capacity Act 2005.
  • All staff worked to nationally recognised best practice for substance misuse treatment. Leaders had the skills, knowledge and experience to perform their roles, were visible in the service and approachable for clients and staff. Leaders had undertaken additional training and development, and new comprehensive governance processes had been implemented which ensured that service procedures ran smoothly.

However:

  • The service did not deliver a smoking cessation programme. One client told us they would have liked to have accessed smoking cessation support.

  • The service did not have a specific programme for engaging families and carers and did not actively seek feedback from them.
  • The service had no specific arrangements in place for accessing translation or foreign language support should clients need it.
  • Clients could not lock their bedroom doors.

Inspection carried out on 10 January 2019

During an inspection to make sure that the improvements required had been made

We undertook an unannounced, focused inspection of Addiction Recovery Centre following concerns identified at our last inspection in September 2018. During that inspection, we found the provider was not fully meeting the required standards of care. We had immediate safety concerns and found that the provider was not meeting the requirements to keep clients safe set out in Regulation 12 of the Health and Social Care Act, 2008 (safe care and treatment). We also had concerns about the provider’s management and oversight of the services delivered which is covered in Regulation 17, Good Governance.

We took enforcement action and issued two warning notices in respect of each regulation which required the provider to make immediate improvements. We visited the service on 1 November 2018, we found the provider had met the requirements for the warning notice for regulation 12.

We undertook this inspection (January 2019) to check whether the provider had made the required improvements to the safety of the service.

During this inspection in January 2019, we found that the provider had made enough improvement to meet the requirements of the warning notice served in relation to Regulation 17.

The provider had made the following improvements:

  • The provider ensured that staff received the necessary training to allow them to carry out their roles. An up-to-date training matrix was monitored by the management team. Staff were trained in key areas such as: safeguarding adults, the Mental Capacity Act, detoxification, detoxification monitoring tools, medicines administration. Staff that had not received some of the training at the time of our inspection were due to be booked onto it.
  • The management team had oversight of incidents and accidents that occurred in the service. Staff meetings now included analysis of both incidents and accidents and fed back any learning.
  • Staff audited their own practice. A series of audits took place within the service, records showed that staff followed up on actions from audits.
  • The management team had begun to monitor outcomes for clients. Initial data was available which showed how long clients received treatment from the service, what the outcome of their treatment was and followed up on clients’ status post discharge.
  • The provider had begun sending statutory notifications to the Care Quality Commission and had a system for identifying which events led to a statutory notification submission.

However:

  • The management team were not trained in nor have the relevant support to manage staff performance. There was no human resource support or access to advice available which could lead to staff not being managed and supported fairly. Where there were safeguarding concerns involving staff, thorough consideration to managing staff involved was not given.
  • A safeguarding concern had not been raised with the local authority.

Inspection carried out on 01 November 2018

During a routine inspection

We undertook an unannounced, focused inspection of Addiction Recovery Centre following concerns identified at our last inspection in September 2018. During that inspection, we found the provider was not meeting the required standard of care. We had immediate safety concerns and found that the provider was not meeting the requirements to keep clients safe set out in Regulation 12, safe care and treatment, of the Health and Social Care Act, 2008. We also had concerns about the provider’s management and oversight of the services delivered which is covered in Regulation 17, Good Governance. We took enforcement action and issued two warning notices in respect of each regulation which required the provider to make immediate improvements. We undertook this inspection (November 2018) to check whether the provider had made the required improvements to the safety of the service.

We found that whilst there was still much more improvement required we were assured that the provider was now able to deliver low level detoxification safely. The provider gave assurances that it would only admit clients who required low level detoxification. We found that the provider had made enough improvement to meet the requirements of the warning notice served in relation to Regulation 12.

The provider had made the following improvements:

  • Clients' risk assessments now included detailed plans to manage individual risks, including risks posed through undergoing detoxification. These identified what staff should do in different risk circumstances, including emergency situations such clients’ deterioration, seizures or overdose. Staff demonstrated a clear understanding of what action they should take in an emergency, including how to carry out first aid. Staff knew how to seek help in these circumstances.
  • Clients who were self-administering medication all had risk assessments in place and clients had secure medication boxes that they kept in their rooms to store their medication in. Staff understood both the individual and group risks associated with clients having medication in their rooms.
  • The provider had made improvements to its medicines management protocol and practices; medicines were now stored and managed safely. Staff understood the protocols and had received training and key staff had been assessed as competent in the administration of medicines.
  • The service was now getting summaries from clients’ GPs prior to admission to inform treatment and risks. These were reviewed by the GP who the service used to prescribe medication, who undertook a detailed assessment of clients prior to prescriptions of detoxification medication being issued. The provider had contracted this GP to attend the service on a sessional basis and was also in the process of recruiting a registered nurse who would provide support to staff and also ensure clients were supported through detoxification safely.
  • Staff who had positive criminal disclosures on their disclosure and barring service certificates now had risk assessments; although these needed to be more detailed.

  • The provider had amended its website to more accurately describe the service it was able to offer.

Inspection carried out on 17 September 2018

During a routine inspection

We rated Addiction Recovery Centre as Inadequate because:

  • Following its inspection, the Care Quality Commission issued two warning notices due to immediate concerns about the safety of clients using the service. We required the provider to make significant improvements to the safety of the service by 9 November 2018 and to the governance of the service by 21 November 2018. In response to our concerns the provider agreed voluntarily not to take any further admissions until it had made the improvements to address the safety concerns.
  • Addiction Recovery Centre did not provide safe residential detoxification for clients that was in line with national guidance and best practice. There were no clinical staff employed by the provider to oversee detoxification and the staff who were supporting clients through detoxifications were not trained or assessed as competent to support them safely. Staff did not use and were not trained to use drug or alcohol detoxification monitoring tools. The only clinical involvement was from the GP who prescribed the initial detoxification regime and had no further involvement unless there was a problem.

  • Pre-admission assessments were not robust and staff sought either no or limited health-related information from the clients’ GP. Staff did not undertake sufficiently detailed or thorough individual risk assessments of clients. Risk assessments did not indicate what actions staff should take in situations that endangered the clients’ health or wellbeing. For a number of clients, the assessments did not include relevant health concerns that should have been considered when planning care.

  • Staff did not manage medicines safely. Clients’ had no way of keeping their medicines safely in the accommodation. Staff had not undertaken risk assessments of clients who were self-administering medicines. Medicines were not sufficiently labelled on dosage boxes. Two staff members who held keys to the medicines cabinet and administered medicines were not up-to-date with their medicines administration training.
  • Staff were not trained to the required standard to help them carry out their role. Staff did not receive training in safeguarding or the Mental Capacity Act. Staff did not consider clients’ capacity to make decisions whilst under the influence of alcohol or drugs. Clients told us they could not remember signing consent forms at the start of treatment because they were under the influence of drugs or alcohol. This also included signing for consent to payment. The mental capacity policy did not direct staff to reassess capacity at a more suitable time if clients were under the influence. Policies were not written in line with the Mental Capacity Act.
  • Staff had not received up-to-date training in basic life support and were not trained in safeguarding adults at risk or in child protection. Staff had not completed all the training requirements of the provider’s induction policy. Not all staff had commenced the diploma level 2 in health and social care or a number of health and safety topics that the policy detailed that they should have completed.
  • The provider told us that there had been no serious incidents in the last 12 months. However, we discovered that a serious incident had occurred but this had not been reported to the local safeguarding team or CQC, as required by regulations. It is unclear whether any additional incidents had occurred as staff did not always record or investigate adverse incidents. There was no evidence that staff learned from and changed practice as a result of incidents
  • Leaders lacked an understanding of what constituted a safe, good quality residential detoxification and therapy service. They lacked an understanding of what was required to meet CQC regulations in delivering the service.
  • The governance arrangements were unclear and did not enable the provider to manage or monitor the quality of the service it delivered. Key information was not discussed at staff meetings and there was no process in place to review key items including; incidents, complaints, safeguarding, training and supervision. There was no framework for reviewing and updating policies and procedures or any record that staff had read and understood policies and procedures the provider did not monitor outcomes or have any indicators to monitor the performance of the service.
  • The provider had not made adequate employment checks on staff working for the service. They did not undertake risk assessments for staff who had positive disclosures on their Disclosure and Barring Service certificates. Staff employment files were not well maintained. Contracts, roles, job descriptions and hours of work were not up-to-date.
  • The provider was misrepresenting what treatment interventions it was delivering in its documentation and on its website. The provider advertised that it delivered therapies such as cognitive behavioural therapy, dialectical behavioural therapy and transactional analysis. The majority of staff were not trained to deliver such therapies and told us they did not deliver these but they used an approach based on cognitive behaviour therapy.
  • The terminology used in one of the client’s records was derogatory and offensive. There were inappropriate statements in the service user guide which had caused offence to clients. Staff did not respect clients’ privacy. They had looked through client’s phones and did not see a problem with doing this. Clients told us they were concerned about having to let staff see their personal mobile phones.

  • Complaints were not always recorded and were not responded to with empathy and compassion. We reviewed responses to complaints and found that the language used was judgemental and accusatory.
  • The provider had not carried out legionella testing and was not aware of the requirement to do so.

However:

  • The environment was clean and tidy and the furnishings were in good order and there were adequate counselling and group therapy rooms. Clients’ accommodation was comfortable.
  • Leaders of the service and staff described a passion for supporting people to recover. The service had a full complement of staff and no vacancies and staff received regular supervisions and appraisals
  • Clients were positive about the interactions they had with staff and their keyworkers. Clients felt involved in their care. Clients felt they could raise concerns if they had any. Staff at the service had recently collected and analysed feedback from clients. Small changes had been made to the service as a result.

  • Immediately following the inspection, the provider took the following actions:

sourced and booked staff onto training in the Mental Capacity Act for staff

ordered lockable storage for medicines as soon as we identified concerns about clients not being able to keep their medicines safe

We returned to the provider on 01 November 2018 as the provider informed us that it was going to start admitting clients again. We wanted to check that the provider had made improvements and was able to provide a safe service to clients. We undertook a focused inspection and found a number of improvements. These are summarised in a separate report.

Inspection carried out on 12 October 2016

During a routine inspection

We do not currently rate independent standalone substance misuse services.

We found the following areas of good practice:

  • Staff and management were client focused and dedicated to ensuring clients’ success on the programme. Staff treated clients with courtesy, empathy and respect, and encouraged clients to give staff open and honest feedback throughout their treatment. This approach gradually empowered clients to take control over their life through to designing their own exit plan for when they reintegrated into the community.
  • Prescribing for detoxification clients was through one of two GPs at the same practice who took clients through a detoxification checklist, including a physical examination. The GPs then prescribed to a given regime, which are within the National Institute for Health and Care Excellence (NICE) guidelines.
  • Staff turnover and sickness absence was 0% in the previous 12 months. Clients and staff confirmed that the service had not cancelled any activities, groups or meetings in this period. Management and staff monitored and reassessed caseloads regularly. The maximum caseload for a key worker was six clients.
  • Clients were involved with a local recovery community in Portsmouth as part of the programme and this helped them to visualise how their recovery could continue once back in the community. The services provided by the local recovery community were user involvement, peer led advocacy, one-to-one peer support and mentoring and a range of recovery focused groups.
  • The service carried out a full assessment of the client's history before accepting them onto the programme. This included gaining information from other related services. Clients said they were involved in their care plans, which they regularly discussed with staff in their one-to-one meetings and more formally at six weekly reviews. The centre also asked clients to complete a questionnaire about the service. It consulted them on the issues that arose from this and their preferred solutions.
  • The service had a clear complaints policy, which staff and clients understood. However, as clients were encouraged to speak up for themselves throughout the programme, all five we spoke with said they would prefer to raise an issue or complaint with their keyworker first.

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

  • There was no supervision of clients when they returned from their groups to the service accommodation at night and during the weekends. The service relied on the other clients within the house to raise an alarm with the service manager or director by phone if an issue occurred. This meant clients undergoing alcohol detoxification could be at risk of suffering physical harm without effective monitoring of the initial phase of alcohol detoxification.
  • The clinic room did not have hand-washing facilities despite staff screening urine in there regularly. Staff used alcohol hand gel in line with Addiction Recovery Centre’s Infection Prevention and Control Policy.
  • Cleanliness in the upstairs toilet was poor on the day of inspection.
  • The provider was not registered for the regulated activity of ‘accommodation for persons who require treatment for substance misuse’ and clients were required to stay in the accommodation provided as part of the treatment. The provider took immediate action to rectify this.
  • There were no fitted alarms in the rooms used for one-to-one meetings and keyworkers did not have personal alarms. Clients told us staff held some one-to-one meetings with the door open, compromising privacy.
  • The kitchen area was small and the location of the toilet within this room was not in line with infection control and clients’ privacy and dignity.