We rated Livingstone House Good overall because:

• The service provided safe care. The environment was safe and clean. The service had enough staff and they assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely 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 client group and in line with national guidance and best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• Managers ensured that staff received training, supervision and appraisal. The staff worked well together as a multidisciplinary team and with those outside the service who would have a role in providing aftercare.
• Staff truly respected and valued people using the service as individuals and empowered them to understand and manage their care. They treated clients with dignity, compassion and kindness. They understood the individual needs of clients and supported them to understand and manage their condition.

• Staff actively involved clients and families and carers in care decisions. Staff involved families and carers and provided them with exceptional levels of support. Staff actively worked with clients and their families to rebuild broken relationships caused by addiction.
• The service provided a range of treatment options including detoxification, day care, aftercare, resettlement, peer support and volunteering. Staff planned and managed discharge well and liaised well with community services.
• The service was well led. Staff were undertaking a programme of improvement and updating governance processes to ensure the service ran smoothly.

This was not an inspection of all the locations of Livingstone House. We inspected Livingstone House and Serenity House.

We talked to people who used the service. People were happy with the service they received, and told us "I would probably be dead if it wasn’t for this place, its literally saved my life”.We saw patients being cared for by compassionate and dedicated staff.

People told us and we looked at patient records which confirmed staff involved people in their treatment plan, and included the person's input in determining goals to be achieved.

We reviewed treatment records, which held chronological information about the initial referral, assessments and treatment progression.

We talked with six staff who told us they were well supported by the manager, but when speaking with the manager and reviewing practices we found there was insufficient registered nursing staff to meet people’s needs.

We reviewed the arrangements for ordering, storing, dispensing and disposal of medicines, and found that management of medicines required improvement. We saw the process for auditing medication was in place and conducted monthly.

There was a robust governance system in place to measure the quality of care and treatments for patients. An extensive range of policies and procedures were available however they were either out of date or contained outdated information.

Patients were encouraged to feedback regularly on their experiences of the service.

We do not currently rate standalone substance misuse services.

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

• Ligature risks were not mitigated despite the service admitting clients with current and historic risk of suicide. This was a breach of a regulation. You can read more about it at the end of this report.
• Cleaning equipment and substances hazardous to health were stored in an outdoor unlocked shed which was accessible to clients. There was no system to audit the contents of the shed. This was a breach of a regulation. You can read more about it at the end of this report.
• Environmental risk assessments were in place but did not show evidence of regular review or evidence of change. This was a breach of a regulation. You can read more about it at the end of this report.
• Client records concerning night handover sheets could not be located on the day of inspection. These were found and provided to CQC the week following the inspection. Information governance systems for the filing of care records were not being maintained. This was a breach of a regulation. You can read more about it at the end of this report.
• There was no emergency call system in place. This was a breach of a regulation. You can read more about it at the end of this report.
• There were no maintenance records for the building over a period of 15 months. Some cleaning records were missing.
• We found one instance of medication not stored correctly within the clinic room.
• Staff did not have regular team meetings.
• Information governance was not robust. Information governance systems for the filing of care records were not being maintained.

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

• Client areas and rooms were visibly clean and tidy. The kitchen was cleaned daily and staff maintained good hygiene with food preparation. The clinic room was well equipped and equipment was calibrated and maintained.
• There were no incidents of violence or aggression reported within the service. Staff used verbal de-escalation techniques to manage aggression.
• Staff received mandatory training.
• Care records were in good order and accessible to staff. Staff carried out comprehensive assessments prior to and on the day of admission. We saw holistic assessments of risk, recovery planning and need within care records. Staff undertook blood borne virus assessment and vaccination, alcohol audits were completed where appropriate. All client records contained an up-to-date and detailed risk assessment and management plan. Plans reflected the individual needs of the clients and were signed by clients. All client records contained up-to-date, recovery orientated and individualised plans.
• There were good procedures in place for administration and management of medication. Staff carried out appropriate physical observation of clients during detoxification. We saw good practice in in relation to prescribing for detoxification. There was one serious incident in relation to medication administration recorded in the 12 months prior to inspection. We saw thorough learning from the incident and changes made to practice as a result.
• There were adequate numbers of staff and nursing cover for the service and access to a nurse or doctor 24 hours a day through use of on-call rota. Physical health and nutrition monitoring was carried out throughout detoxification. Staff carried out regular drug and alcohol testing throughout treatment. There was a process for clients to request additional medical reviews from the nurse should they want it. The service followed the National Institute of Health and Care Excellence when prescribing medication.
• The service routinely engaged clients’ family members in the recovery process. The service had a broad and structured therapeutic programme based around the 12-steps. There was a timetable in place for clients which included activities at weekends. The service offered an additional Christian programme.
• There was an appropriate skill mix of staff at the service. Staff received training and induction. We saw evidence of regular supervision and annual appraisal. There were regular multi-disciplinary team meetings between staff and the partner GP. Staff carried out appropriate and detailed handover between shifts. Staff showed knowledge of individual clients during discussions with each other in handover.
• All clients we spoke with were happy with the service provided. Clients told us staff were caring, supportive and helped them. They told us the service met their needs and they felt accepted. Staff interacted positively with clients and showed knowledge of individual clients and their needs.
• Clients were aware how to complain or give feedback on the service. Feedback from clients was used to improve the service. Clients had regular meetings to give feedback on the service.
• Discharge planning was carried out from the point of admission and staff planned well for unexpected discharge.
• The service had a broad and structured therapeutic programme based around the 12-steps. There was a timetable in place for clients which included activities at weekends. The service offered an additional Christian programme but also supported clients to access their own spiritual and religious needs.
• Staff morale was good and there were opportunities for staff to develop in their roles.
• Clients who had completed treatment were given opportunities to access employment and voluntary opportunities within the service.
• The service had low sickness rates and there were no whistleblowing or bullying cases associated with the service.