We rated Chelmsford as good because:

• The service was clean and tidy and furnishings were of good quality. The clinic room was clean and well organized. Emergency equipment was in date, regularly tested and ready for use. There were enough rooms for clients to use for groups and therapy.
• The service had developed protocols for opiate and alcohol detoxification. The doctor and registered nurse completed medical assessments for all clients on the day of admission, including physical health checks, to ensure they were suitable for the detoxification programme. Clients who were not suitable for the detoxification programme were signposted to other services. Staff had completed mandatory training including how to support clients undergoing detoxification.
• The doctor saw all clients on admission and staff could contact the doctor for advice and to visit the service if required, seven days a week and out of hours. Access to the service was quick and easy and there was no waiting list.
• Staff completed risk assessments and reviewed them regularly. Staff completed assessments which were holistic and focused on discharging clients back to living in the community. Client records contained contingency plans in the event of patients unexpectedly discharging themselves from treatment.
• The service followed good practice in prescribing medication in line with current guidance and best practice. Staff used recognised treatment outcome measures. There were safe processes in place for the management and administration of medication. Staff were trained in medicines management and administered medicines safely.
• Clients had access to psychological therapies and individual counselling sessions with an identified counsellor. Staff developed care plans with clients and reviewed and updated these regularly.
• Staff received management supervision in line with the provider’s policy. Therapy staff also received monthly clinical supervision with an external counsellor. Most staff reported that morale was good and they felt respected and supported.
• Staff treated clients with kindness, compassion and respect, showed an understanding of their needs and offered appropriate emotional support. Staff helped clients understand their condition and treatment and access specialist services where appropriate. Clients told us staff were caring and kind and genuinely interested in their wellbeing. Clients were involved in their care, reviewed their plans with staff weekly.
• Clients told us that staff listened when they raised concerns and took action to resolve them. Staff discussed client requests at the daily handover meetings and agreed what actions they would take. Staff supported clients to maintain contact with their families and with outside agencies such as fellowship meetings, housing, education and employment.

However:

• The ligature risk audit classified all ligature risks as low, including in areas where clients had unsupervised access, and identified no additional control measures. There was no sink or facilities to dispose of waste water in the clinic room. Staff used urine testing equipment in the toilet area.
• Numbers of therapy staff at the centre had decreased since the last inspection. The provider had introduced a rota to provide additional staff to the detoxification house but had not recruited additional therapy staff to facilitate this.
• Staff did not document that clients received copies of their care plan and three of the six care plans we looked at did not record client views or involvement.
• Managers had not ensured that learning took place consistently in relation to all incidents and complaints. Documentation was inconsistent, lacked detail and was sometimes contradictory. Managers had not ensured that staff had reported medication administration errors as incidents and shared learning about this across the service.
• Mental Capacity Act training was brief. Two staff told us they had not received any training in the Mental Capacity Act. Some staff were not aware of policies in relation to lone working and the management of seizures.
• The service did not admit people with mobility issues to the detoxification programme. Although the centre could accommodate people with mobility difficulties, all bedrooms at the detoxification house were upstairs and there were no lifts.
• Managers did not have easy access to information to monitor the quality of the service and did not have performance indicators to highlight strengths and risks.

We do not currently rate independent standalone substance misuse services.

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

• The ligature audit did not address whether risks could be further reduced or eliminated or state how the risks were managed. Staff told us that if any clients were at risk of using ligatures this would be addressed through individual risk assessments. However, individual risk assessments for clients with a history of self-harm or suicidal thoughts did not address this.

• Staff did not routinely complete blood borne virus assessments in full on admission.

• Staff did not have access to hand washing facilities within the clinic room. This was a risk to patients and staff; relating to the spread of infection.

• The service continued to be understaffed at weekends. Managers had attempted to recruit to additional posts to address this.

• The service had not ensured that all clients had a full physical health assessment on admission which was documented in clients’ records.

• Some care plans lacked detail and contained limited information including details of any treatment goals.

• Staff responses to issues raised by clients were inconsistent and poorly recorded.

• The provider did not have a clear definition of what constituted a serious incident or a clear framework in place to indicate how this would be investigated.

• The service did not record how staff learned from complaints and concerns and it was not clear how learning was fed back to the staff team.

• The provider did not have processes in place to ensure that people who did not speak English had easy access to information about the service.

• Conversations in the large meeting room could be overheard in the corridor and adjacent rooms.

• The service did not have targets or processes to monitor the performance of the team.

• There was no systematic follow up of clients leaving the service to monitor the effectiveness of the service or outcomes for patients.

• The provider did not have clear guidance for the requirements of compliance with mandatory training for all staff; which detail how often staff should repeat training.

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

• The clinic room was clean and tidy and contained a range of equipment used to carry out physical examinations with clients. The treatment centre and the detoxification house, where clients lived during their detoxification programme had naloxone and resuscitation equipment with easy access. Naloxone is used to treat a narcotic overdose in an emergency situation.

• The doctor saw all clients on admission and could be contacted for advice and to visit the service if required, seven days a week and out of hours.

• There were safe processes in place for the management and administration of medication, including recording the use of homely remedies. Staff were trained in medicines management and administered medicines safely.

• A qualified nurse oversaw the detoxification programme, including blood pressure, urine testing and monitoring medication used during the detoxification programme and monitoring clients’ physical health.

• The doctor completed medical assessments for all clients on admission, including physical health checks, to ensure they were suitable for the detoxification programme.

• The service followed good practice in prescribing medication in line with current guidance and best practice, and managing and reviewing medicines following British National Formulary (BNF) recommendations.

• Clients had access to psychological therapies and individual counselling sessions with an identified counsellor. There was a full range of treatment groups and activities throughout the week.

• Staff morale was high and staff were motivated to help clients in recovery.

We do not currently rate independent standalone substance misuse services.

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

• Senior managers did not follow the service recruitment policy. Interviews were not appropriately recorded and risk assessments were not completed for workers with previous convictions. There were discrepancies in start dates and Disclosure and Barring Service (DBS) checks for employed staff. Peer supporters had started working in the service without training and appropriate DBS checks and were not supervised appropriately by managers.

• The service was understaffed during the weekends, compromising staff and patient safety.

• Storage temperatures for medication and urine testing kits stored in the clinic room were not checked daily to ensure they stayed within the recommended temperature range, which could mean there was a risk to their effectiveness.

• The provider did not have a structured induction process for new staff members.

• The house where clients stayed during detoxification was not safe. The hinges on the fire door in were broken. This was a breach of both health and safety, and fire regulations. The low fencing in the back garden of the property did not promote privacy and dignity for the clients living there. Staff working in the detox house did not have access to naloxone (used to reverse the effects of opioids) or resuscitation equipment. Staff were trained in basic first aid and could call emergency services if required.

• The clinic room was not fit for purpose. The floor was carpeted and the room had soft furnishings, so staff could not wipe down surfaces, meaning there was an infection control risk. In addition, it was used as a staff office.

• Staff did not follow up on clients that had been discharged from treatment and the service had no information about clients remaining drug free after treatment, meaning the effectiveness of treatment was not being measured.

• Staff started to record incidents of harm or risk of harm on a log in October 2015, entries were poorly recorded and outcomes were not followed up.

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

• Staff completed timely and comprehensive assessments with all clients accessing treatment, including physical health, mental health and risk assessments.

• Doctors completed medical assessments within 24 hours of a client’s admission for detoxification; this included a physical examination to ensure suitability for treatment.

• All employed staff were trained in safeguarding adults from abuse and knew how and when to make referrals to safeguarding teams.

• Staff had positive working relationships with external agencies such as local GPs and mutual aid groups whilst clients were in treatment.

• Clients spoke highly of the staff and said that they treated them with support and compassion.

• Staff employed by the service worked well together and were passionate when talking about their roles.

• PCP provided move-on accommodation for clients post treatment that were homeless or wanted to relocate to the area. Clients living in the move-on house could still access on-going support or become a peer mentor.

We found that staff always discussed confidentiality with people who used the service and gained their consent to share information about them with other healthcare professionals. People were also asked to sign that they understood and agreed to their care plan.

We spoke with two people who used the service who told us they found members of staff were very supportive. When we reviewed care records we found that they contained clear assessments of people's needs and this was reflected in their care plans. People attended regular appointments and staff provided them with support and advice. They also referred them to other services when it was relevant to do so.

Staff took relevant actions and worked with other professionals to ensure that people who used the service or those close to them were protected from the risk of abuse. They were knowledgeable about safeguarding procedures and followed clear and up to date policies.

People were protected against the risks associated with medicines because the provider had improved arrangements in place for the management and recording of medicines.

Records that we reviewed were well maintained, stored safely and securely.

During our last inspection, on 06 June 2012 we issued a compliance action with regard to the inadequate ventilation within the offices. The windowless offices had no access to ventilation and conditions were stifling for staff to work in. We revisited the location on 24 January 2013 to review the necessary improvements for compliance. The manager showed us plans for a ventilation system to be installed. This will ensure the premises have ventilation that conforms to relevant and recognised standards.

We spoke with two people using the service. They told us that they were satisfied with the arrangements for their medicines and that they received their medicines on time. They told us that staff had explained what any newly prescribed medicines were for. People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

People we spoke with told us that the staff team provided the support and care they needed. One person said “I knew what I had signed up for was difficult at first but the staff were always there, I am glad I stuck it out it has been a good experience.”

During our visit we spoke with people attending the clinic, members of staff, and the registered manager.

People told us that they were asked for their views about the running of the programme by the manager and staff. They also told us that they felt confident taking any concerns to staff members or the manager direct if needed. One person told us that, “We have daily reflection diaries that we take away with us this is a good reminder of how we coped throughout the programme.”