This was an unannounced focused inspection relating to issues identified at a previous inspection in March 2017.

Following the inspection in March 2017, we issued two warning notices. They were issued under Regulation 12 (safe care and treatment) and Regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

On this inspection we found

• The provider had made significant changes and had met the requirements of both warning notices.
• Client risk was effectively managed. Risks were assessed and identified during the assessment process. Risk management plans were in place and being followed. Physical observations were being carried out in accordance with best practice and withdrawal symptoms were being monitored.
•  Medication was being administered in line with identified prescribing regimes. Staff had been assessed as competent to administer medication. Prescription charts and medication administration records were completed properly, signed and dated. Medication was stored safely.
• The service was auditing the quality of care. The team manager conducted weekly audits of client records. The provider completed a quarterly quality and compliance audit.

This was an unannounced focused inspection relating to issues identified at a previous inspection in August 2016 following which we served warning notices. We do not currently rate independent standalone substance misuse services.

Following a comprehensive inspection in August 2016 we issued a warning notice under regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At this inspection we assessed whether the service provider had put right issues identified in the warning notice. We found some improvements had been made. However not all areas had been addressed.

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

• The service was not administering medication safely. Medication administration records were not always completed properly. There were gaps in signatures to confirm administration. Prescription charts were not always signed by a doctor. We found some prescription charts were duplicated. Staff administering medication had not been signed off as competent to do so.

• Physical health and withdrawal symptoms were not being monitored effectively. Physical health observations requested by the doctor were not always being completed. Staff completed Clinical Institute Withdrawal Assessment for alcohol scales on admission. However these were not repeated consistently.

• Staff had not completed medication management training at the time of the inspection. However evidence was provided to show that staff had been booked onto training.

• Staff were monitoring fridge temperatures. However the thermometer did not allow them to record minimum and maximum temperatures.

• There were gaps in medication management. There was a system for auditing medication stock levels. However clients’ own medication was being recorded on a separate sheet. This meant that the provider’s policy was not being followed. Controlled drugs were being managed in accordance with legislation. A new medicines policy had been developed. However there was no date of issue on the policy.

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

• Staff we spoke with had either received basic life support training or had been booked to attend training.

• There were two adrenaline pens on site. Staff had undergone training in their use.

Following the comprehensive inspection in August 2016 we issued a warning notice under regulation 17 of the Health and Social Care Act 2008 (regulated activities).

At this inspection we assessed whether the service provider had put right issues identified in the warning notice. We found some improvements had been made. However not all areas had been addressed.

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

• Robust systems There was a lack of audits in place. Staff told us that a care record audit was completed monthly. However, the provider shared results verbally with staff and there was no documentation to evidence this. The provider’s quality assurance programme requires the service to complete at least two different audits each year.

• Risk assessments were completed. We found some evidence of risk management plans. However there were risks that had been identified that were not addressed in risk management or care plans.

• There was a ligature audit. This identified the level of access clients had to rooms with ligature points. There was no additional assessment or mitigation in place. However mental health was part of the pre-admission assessment for clients. The service did not admit individuals at risk of suicide.

• Not all policies and procedures had been reviewed. Several policies were overdue for review. There was a box on the front page to evidence that review had taken place.

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

• Care plans were complete and up to date. Clients’ goals and objectives were captured using the wheel of life tool.

Following the comprehensive inspection in August 2016 we issued a warning notice under regulation 18 of the Health and Social Care Act 2008 (regulated activities).

At this inspection we assessed whether the service provider had put right issues identified in the warning notice. We found some improvements had been made. However not all areas had been addressed.

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

• Data on compliance with mandatory training was not available during the inspection. Staff we spoke with told us that training had been discussed in team meetings and that they had training dates booked in.

• Staff appraisal rates remained low. However staff we spoke with were able to tell us the dates of their planned appraisal. They had been given a pre-appraisal assessment to complete as part of the process.

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

• Staff informed referral agencies if they were unable to accept referrals due to the consultant psychiatrist being unable to attend. Staff knew how to contact GPs and emergency services in the event of a medical emergency.

Following the inspection we held a management review meeting to discuss the findings. We issued a letter of intent to the provider, requesting further information and assurance. It also laid out the regulatory and enforcement actions available to the CQC if regulations were not met.

We carried out a focused inspection to check whether improvements had been made since our last inspection in June 2015.

We found that:

• The provider had taken action to address concerns regarding premises, particularly in relation to fire safety.

• The provider had taken action to address concerns regarding safe staffing, recruitment and supervision procedures.

• The provider had taken action to address concerns regarding safeguarding arrangements.

• There was improved and visible leadership within the service.

• The provider had taken action to address the concerns regarding quality checks.

This all meant that the provider had taken sufficient action to address the issues we raised in two warning notices, which we issued in July 2015 following our last inspection.

However, on this inspection we found that:

• Personal evacuation plans were not fully individualised.
• One patient admitted with identified pressure ulcer sores was not receiving appropriate treatment to ensure their ulcer sores did not worsen.
• Care plans were not fully detailed as they did not explain what care and treatment people would receive.
• The safeguarding policy and complaints policy did not properly tell people about our role in complaints and safeguarding.

We have issued a requirement notice to the provider telling them they need to improve their arrangements to provide safe care. We will monitor the action they take.

During our visit to the service we found;

Several area's of serious concern regarding fire safety issues. These issues placed staff and people who used the service at risk which was avoidable. We reported our concerns to the local Fire service

Policies and procedures which were out of date

A lack of evidence to demonstrate effective monitoring of the service provided to drive improvement

Staffing rota's which did not reflect actual staffing levels

Lack of supervision for staff

Staff records which were missing or incomplete

A lack of visible leadership  

However, we also found that;

People who used the service were very positive about the care and treatment they were receiving from staff within the service

The service provided care and treatment which was evidenced based and supported people's recovery

The service provided a range of therapies and facilities to assist people with their recovery

Staff were motivated and committed

We do not currently rate independent standalone substance misuse services.

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

• The service did not have suitable arrangements in place for the administration and management of medicines. Staff had not been trained in the necessary skills to treat a patient in the event of an emergency. Records of controlled drugs were not always completed in accordance with the National Institute for Health and Care Excellence guidance. Fridge temperatures were not monitored. Medicines and Healthcare products Regulatory Agency guidelines were not observed. Physical observations had not been completed as directed by the doctor for some clients. Observations out of the normal range were not being escalated to the registered manager. The service did not assess client’s withdrawal symptoms during the detoxification regime which was not in accordance with national guidance. Prescription charts were not being used in accordance with legislation. We issued a Warning Notice under section 12 of the Health and Social Care Act 2008.

• Policy management was poor. Of all the policies we looked at only two had been signed to say they had been reviewed. There were three different versions of the complaints policy available. The equal opportunities policy and diversity in care policy did not mention the most recent legislation of the Equality Act 2010.Two versions of the service user handbook had incorrect information regarding CQC involvement in complaints. We issued a Warning Notice under section 17 of the Health and Social Care Act 2008.

• There were not sufficient qualified staff to provide care. The registered manager was the only qualified permanent member of staff which meant that the registered manager was always on call as there were no other staff with sufficient skills to cover for the manager. Lack of qualified staff meant that client care was compromised. Clients did not always have access to a psychiatrist as there were no cover arrangements for the consultant psychiatrist if they were off sick or on annual leave. We issued a Warning notice under section 18 of the Health and Social Care Act 2008

• Staff performance and continuing professional development was not being regularly reviewed. The registered manager for the service had not received an appraisal and three of the eight permanent staff had not received appraisal as per the policy. There was no documented supervision completed for the registered manager. They did not receive clinical supervision from a suitably qualified person. We did not receive information to confirm that the doctor had received supervision from a specialist substance misuse doctor. The service did not support staff to access specialist training. We issued a Warning notice under section 18 of the Health and Social Care Act 2008

• Mandatory training was not being provided in line with the training policy for the service. The majority of staff had not completed any training in the policy. Safeguarding training was not part of mandatory training but the safeguarding policy stated that all staff should be trained in this.

• Care records were poorly completed. They did not document recovery aspects and goals of treatment. The medicine administration record did not have space for the persons address or date of birth or allergies. It was unclear who was making changes on these records. There were no contemporaneous notes for medicines. There was no documented observations of a person’s physical health using a recognised tool. Initial assessments from the all of the referring agencies except one gave limited information on the presenting problems of the client and there was no standardised way of capturing this information.

• Systems were not in place to identify shortfalls in standards of care and making the necessary improvements. No internal audits had been carried out since August 2015. There were no identified quality improvement measures in place and no system to ensure the service was following best practice guidelines.

• The safeguarding policy did not state that CQC were to be informed of safeguarding alerts or concerns which meant that staff were not aware of the need to notify CQC.

• Environmental risks were not being effectively managed and mitigated. Ligature assessments did not identify ways to reduce or manage these risks.

• Not all staff had the relevant checks such as photographic identification, disclosure and barring service which is a regulatory requirement.

• The exit door from the third floor fire escape had no signage to say the exit was to be used a fire escape only.The exit led to a flat roof and then down the external metal fire escape. The flat roof had a railing fence around it. The fence was waist height and was not a solid structure. It was therefore possible for someone to slip under the barriers and fall

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

• All areas of the building including the bedrooms and bathrooms were clean and well maintained. Fire evacuation procedures and checks were regularly completed

• Clients had access to a range of therapies and interventions to promote their recovery. Group sessions were interactive and informative. Staff established therapeutic relationships with clients and involved them in their care.

• Staff treated clients with respect and kindness and supported them throughout their stay. All clients had full involvement with their treatment throughout their stay. They made decisions about their treatment during sessions with their keyworker. Staff supported clients to engage with support groups in their locality following their discharge.

• There was an aftercare group provided by the service which clients could access for up to a year after leaving the service.

• Sickness and absence rates were low. There were no bullying and harassment cases ongoing. Staff felt confident to raise concerns to either the registered manager or more senior managers.