We do not currently rate independent standalone substance misuse services.

We undertook this unannounced, focused inspection to determine whether PCP Clapham had made the required improvements following the January 2018 inspection. At the January 2018 inspection, the provider was served a warning notice for not providing safe care and treatment. The main purpose of this inspection was to focus on the concerns raised in the warning notice. We also looked at other areas where we had required improvements to be made.

At this inspection, we found the provider had made sufficient progress for the warning notice to be lifted and requirement notices had been fully or partially met. There was however further work needed to ensure the provider safely met the needs of people using the service.

• Whilst all clients had risk management plans further work was needed for clients with physical healthcare needs to ensure this was addressed as part of the treatment delivered by the service.

• The provider needed to review the exclusion criteria for the service. This must clarify whether the service will accept clients for alcohol detoxification and confirm it had the appropriate care and treatment in place to deliver this safely.

• Staff needed to complete the mandatory training and also other training to meet the specific needs of the clients. This included break-away training for staff working on their own at weekends.

• The provider needed to ensure that client outcomes were measured including following up their progress after discharge.

• The provider needed to ensure robust governance processes were in place to ensure safe and effective care and treatment is delivered at all times to clients. This needed to include ongoing clinical audits to provide assurance.

However, we found the following areas of improvement:

• At our previous inspection, we identified that staff did not routinely complete cognitive assessments for clients starting detoxification . At this inspection, we observed that staff now conducted routine cognitive assessments for all clients at risk

• The provider had calibrated all physical health monitoring equipment.

• The provider now had an adult’s safeguarding policy, safeguarding lead and flow chart to support staff to make decisions around safeguarding, although further work was needed to ensure they safeguarded children.

• The provider now had an on-call rota with a senior manager and service manager available on weekends.

• The provider developed an action plan, and had begun making improvements, to minimise the risk of fire.

During our last inspections of the service in May and July 2015, we identified serious concerns regarding the care and treatment of patients admitted for alcohol and opiate detoxification. There were no detailed protocols in place to support staff caring for patients going through detoxification from alcohol or opiates.

The admission criteria were unclear. Staff had no guidance regarding the safe admission and treatment of patients undergoing detoxification. They had not received training regarding the health complications of withdrawal from alcohol and/or opiates or the physical health checks they needed to carry out.

Due to the serious concerns identified, we served the provider a Section 31 of the Health and Social Care Act 2008 notice, on 3 August 2015, to impose a condition in relation to their registration to provide the regulated activity of treatment of disease, disorder or injury. PCP (Clapham) Limited was not to admit patients who required assisted withdrawal from alcohol or opiates to PCP Clapham, Unit 2, 376 - 378 Clapham Road, London SW9 9AR until improvements had been made.

We carried out a focussed inspection of the service on 22 December to check whether the provider had developed improved arrangements and systems to ensure the service could provide safe care and treatment to patients during detoxification.

At this inspection, we found that the provider had put new procedures and protocols in place to make sure detoxification could be safely provided. Staff had received training in how to care for patients undergoing alcohol and/or opiate detoxification. They knew the checks they needed to carry out and the possible health risks to patients during detoxification. The provider had complied with the condition imposed upon them and had made improvements.

We spoke with four people who used the service during our inspection. They told us they received good quality care from the provider. One person told us "I can’t fault the care here". We reviewed a sample of care records, six in total, and found that each contained an assessment of people’s needs and a plan as to how to meet those needs.

The provider had safeguarding policies and procedures in place. The staff were able to explain what the reporting processes were to the local authority safeguarding adults team if any concerns were identified regarding a person’s safety.

They were recruitment processes in place and associated information regarding the recruitment process was found on the two staff records we reviewed.

The provider had in use quality assurance tools for assessing and monitoring the quality of service provision. The provider had met the requirements relating to registered managers and a registered manager was in place.

When we visited in February 2013, we had major concerns with how the provider was managing medicines. People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines safely. We asked the provider to send us a report informing us how they would address these issues. We visited again in April 2013 to follow up on this, and we found that the provider had taken action to address the issues. Appropriate arrangements were now in place to manage medicines safely.

People who use the service told us that they felt that their needs were being met. They said the counsellors were “ very caring and helpful”. However we found that people did not experience care, treatment and support that met their needs or protected their rights. People were going through a detoxification process and clinical support was not available.

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

Staff told us that there was “limited training provided” Staff were not trained in protecting vulnerable people and were not aware how to recognise potential abuse or how to report with the local authority.

The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.

We do not currently rate independent standalone substance misuse services.

We identified areas that the provider needs to improve. We issued a warning notice under Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment.

• During this inspection we saw that whilst some improvements, identified at our previous inspection in December 2016, had been made, other previously identified areas remained outstanding. In addition, some new issues were identified that required improvement.

• Improvements were needed to the premises and equipment. Physical health monitoring equipment was not routinely calibrated to ensure that observations were accurate. This was an ongoing issue from our last inspection in December 2016. A robust plan detailing when and how actions identified in a recent fire risk assessment to make the premises fire safe was yet to be developed. Whilst the premises were visibly clean, records demonstrating the frequency of cleaning were not maintained.

• We identified a lack of effective governance systems by the provider to ensure that safe, effective care was being delivered. For example, the provider did not use key performance indicators to monitor the ongoing performance of the staff team. The provider did not have a formalised audit process to detect areas for improvement in care records, for example. This had not improved since our previous inspection in December 2016. A business continuity plan that outlined how the service would be provided in an emergency, for example if the premises were not able to be used, was not in place.

• Further improvements were needed to ensure that staff were suitably skilled and competent to provide safe care and treatment. During our last inspection in December 2016 we found that the provider did not have a system in place to assess whether staff were competent to administer medications. During this inspection, we found this had not improved. Not all staff had received training to meet the needs of the client group, for example managing self-harm and seizures. Whilst all staff were able to access regular group supervision, volunteers did not receive one to one supervision.

• The provider did not adequately mitigate risks to the health and safety of people using the service. Risk assessments did not provide information about how to safely manage or mitigate potential risks.

• The provider did not have a clear policy or procedure in place detailing the local arrangements for identifying and referring adult safeguarding incidents to the local authority. Staff had a poor working knowledge of safeguarding.

• Clients did not have care plans in place. Although staff and clients told us that a holistic approach to treatment and recovery was taken during their time with the service, there was no framework in place to ensure that the full range of individual needs were identified and appropriately managed. Where clients were prescribed medicines outside of best practice guidance, the rationale for this was not clearly recorded in client care and treatment records.

• Robust arrangements to ensure the safety of staff and clients when staff were working alone on site were not in place.

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

• Since our last inspection in December 2016 the provider had assessed infection risks, and undertook weekly checks to help minimise the risk of infection. The provider had also ensured that the clinic room and physical health monitoring equipment within the clinic room was kept clean.

• Since our last inspection in December 2016 the provider had ensured that disclosure and barring checks had been completed for all staff.

• Staff worked hard to support ongoing recovery. Links were made with numerous mutual aid groups, both in the local area and for specific communities such as the Lesbian Gay Bisexual and Transgender community. Staff also identified support groups in clients’ local areas so they continued to engage with recovery when they left the service. An aftercare group was available for all ex-clients to attend. This helped to embed the principles that were taught during client’s time with the service.

• The service employed former clients as volunteers. They were able to offer mutual support and encouragement. The opportunity to volunteer also helped support their own long-term recovery.

• Feedback encouraged in various ways from clients. Families were invited to provide feedback during families meetings. Staff took time to discuss and reflect on feedback and kept clients updated about progress against issues that they had raised.

• Staff reflected on and identified key learning points or changes that could be made following incidents. Staff understood how to report incidents and discussed these at staff meetings and handovers, aiming to prevent similar incidents reoccurring.