We do not currently rate independent standalone substance misuse services.

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

• Overarching governance of the service was not embedded practice. Management did not monitor new guidance and policy to ensure it was effective. Management did not evaluate and check their quality improvements for effectiveness. The service did not have targets or key performance indicators. Quality assurance management and performance frameworks were not in place. The risk register was incomplete. Registered managers did not have sufficient time, authority or autonomy to carry out their duties effectively. Communication between senior management and location managers and staff was not always good. Not all recruitment processes were robust. The provider did not have clear vision and values.

• Poor cleanliness due to lack of monitoring in the communal kitchen area posed a risk of infection for staff and clients. Managers had not included blind spots on the environmental risk assessment.

• Management had not completed clinical audits. There were no external audits of the processes relating to medicines management and dispensing medication for the three months prior to inspection. The medications policy did not reflect amendments to the health and social care regulations or current guidance around medication management. There was no controlled drugs accountable officer for the service, and in the absence of a drugs accountable officer the provider had not addressed the need to work in partnership with a local pharmacist, or the local controlled drugs accountable officer group.

• Following a medication error management had, considered this to be due to human error and not made any changes to practice. However, they had not considered what changes would reduce the chances of the human error occurring in the future.

• We expressed concern about the providers practice of accepting new referrals on a Friday morning for detoxification over the weekend, when there were no clinical staff on site.

• Three clients and two family members we spoke with were not happy that staff had not invited them to view the accommodation prior to admission or signing their treatment agreement.

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

• The treatment centre had enough staff to provide safe treatment. Staff and doctors had completed comprehensive risk assessments for all clients. Risk assessments included processes to follow for a client who unexpectedly exits treatment. The service rarely cancelled appointments or groups due staff shortages or sickness.

• Staff and doctors completed full mental health and physical health assessments for all clients. Treatment plans were holistic, personalised, and identified client’s strengths and existing coping strategies. Care plans and risk management plans reflected the diverse and complex needs of clients including clear care pathways to other supporting services and support for clients with the transition back to community living.

• Doctors followed good practice in managing and reviewing medicines including following British National Formulary recommendations. The service had embedded relevant National Institute for Health and Care Excellence guidelines. Staff used recognised treatment outcome measures, therapy and support staff had attended specialist training.

• Clients told us access to the service was easy and efficient. The opportunities for their families to be involved and supported during their treatment and the aftercare offered by PCP Leicester were some of the best they had encountered. Furthermore, we saw 21 feedback forms 17 of which praised the staff and the treatment programs offered.