We rated Sanctuary Lodge as good because:

• The ward environment was safe, clean well equipped, well furnished, well maintained and fit for purpose. The manager had completed a risk assessment highlighting any ligature anchor points. Managers kept clear records of environmental risk assessments, incidents, complaints and safeguarding concerns.
• The service had enough nursing and medical staff, who knew the service and staff had completed their mandatory training. The service had a system in place to monitor mandatory training and supervision compliance. The service employed a range of staff disciplines who worked together as a team to benefit clients. The service had effective working relationships with external organisations.
• Staff kept detailed records of clients’ care and treatment. Staff completed and updated risk assessments for each client and used these to understand and manage risks individually. Staff knew how to protect clients from abuse and the service worked well with other agencies to safeguard them. Senior managers engaged with staff and clients on how to improve the service through surveys and staff meetings.
• The service had appropriate arrangements in place for managing medicines. The nurse completed medication audits each month and discussed errors with the team. Staff followed National Institute for Clinical Excellence and Department of Health guidance for treating alcohol and drug dependency. The service utilised complementary therapies and improvements to the environment to support recovery.
• The service treated concerns and complaints seriously. Managers investigated all complaints and they shared learning from these with all staff. The service had received a high number of compliments. Managers measured the performance of the service and collected data to inform service development. Staff knew which incidents to report, how to report them and shared learning from incidents in meetings.
• Staff treated clients with compassion and kindness and supported clients to make decisions on their care for themselves. Clients told us staff supported them with activities outside the service, such as local visits and family relationships.
• Staff felt respected, valued and supported by the team and their managers. The provider was developing staff through extra training to provide a better service.

We found the following areas of good practice:

• All areas of the service were visibly clean and well maintained. The service had employed an extra housekeeper to help maintain standards of cleanliness.
• The service had appropriate arrangements for managing medication. We checked 18 client treatment records and saw appropriate arrangements were in place for recording the administration of medicines.
• Staff completed comprehensive assessments of clients prior to admission. We reviewed five client care records and found that each record contained an assessment of clients’ needs.
• The service offered psychological therapies recommended by the National Institute for Health and Care Excellence.
• Staff assessed clients’ capacity to consent to treatment, prior to admission. If a client was intoxicated when they arrived for admission, staff waited until the following day, before completing admission paperwork.
• We observed staff attitudes and behaviours when interacting with clients. We found staff to be kind, caring, and respectful at all times and treated clients with dignity and respect.
• Families and carers were involved in clients’ care. We spoke to 3 families and carers who told us that staff kept them informed of any changes and invited them to care reviews.
• Clients told us that the food was of good quality. The service had a chef who cooked all food fresh on the premises. Clients told us they had a choice of food.
• Clients had access to activities throughout the week, including weekends. The service had a full activities programme.
• Staff were able to maximise their time on direct care activities. Staff told us that the majority of their time was spent working with the clients rather than undertaking administrative tasks.
• Staff morale and job satisfaction was high. Staff told us how much they enjoyed working within the service and they felt the work was very rewarding.

However, we also found the following issues that the service provider needs to improve:

• There were ligature anchor points in the bedrooms, bathrooms and in communal areas. The service had completed a ligature risk assessment. However, it did not identify individual ligature anchor points or say how staff would mitigate identified risks.
• We had concerns regarding compliance with the Department of Health mixed-sex accommodation guidance. Bedroom corridors contained a mixture of male and female bedrooms. There were no locks on the bedroom doors so clients could not lock the door to maintain their safety, privacy, and dignity.
• The service did not have an alarm call system in place. Staff did not carry personal alarms. Staff would be unable to summon assistance quickly if a client or staff required assistance in an emergency
• Staff were not up to date with mandatory training. We reviewed the services training matrix and found that the mandatory training compliance rate for the past 12 months was 69%.
• Staff completed care plans for clients. However, care plans were not person centred, and lacked detail.
• Staff did not always handle complaints appropriately. The complaints folder did not contain investigations into the complaints. We did not see evidence in two complaints records that staff had thoroughly investigated all aspects of the complaints.

We do not currently rate independent standalone substance misuse services.

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

• The provider had not completed a ligature risk assessment, and had not identified and replaced all ligature risks with non-ligature fittings.
• Risk assessments were not accurate and up to date. Risk assessments did not always identify all risks posed by clients. Staff did not update risk assessments in line with the provider’s policy.
• Medicines management processes were complicated and unsafe. We found 24 medication errors within the month’s period prior to inspection. Twenty of these were documentation errors.
• Staff did not report all incidents. We found two incidents of missing medication that staff had not reported through the incident reporting process. Managers did not always investigate incidents thoroughly and they did not identify lessons learned from incidents.
• Staff were not supervised in line with the provider’s policy. Senior managers were aware that this was an issue highlighted in the previous inspection but had not taken sufficient action to rectify this.
• The provider had not taken action to resolve issues identified in clinical audits. Staff identified risk assessments were not being updated. Managers had not taken action to improve this.
• The provider had not ensured they had completed all action plans relating to warning notices issued by the Care Quality Commission (CQC) in November 2015.

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

• The provider had ensured that staff were up to date with their mandatory training. Staff compliance with mandatory training was 93%.
• Staff treated clients with dignity, kindness, and respect. Clients told us that staff were compassionate, understood their needs and the barriers they may in their recovery.
• The provider had recruited a registered nurse. This was to help staff develop their clinical skills and to improve the quality of care within the service.

We ask the same five questions of all the services we inspect: are they safe, effective, caring, responsive to people's needs, and well led? We normally rate each aspect of a service then give an overall rating. However, we do not yet rate substance misuse services.

• The service did not have robust systems in place to ensure the safe provision of treatment. Staff training and supervision was inadequate, and staff had been employed to work at the service before the provider had received information relating to past criminal convictions. When these had been identified, the provider had not completed an action to mitigate potential risks.

• The service did not ensure the competency of staff administrating medications. Medication errors recorded were not reported through the provider’s incident reporting process. The manager recorded errors in staff supervision notes but did not identify ways in which staff competency would be monitored and supervision did not take place regularly. The provider did not have robust processes for investigating and there was no evidence of lessons learnt from incidents.

• The provider did not have a robust system in place to monitor the quality of care offered to service users. Meeting minutes at staff, board, and community level were not routinely recorded. Service user satisfaction surveys were carried out, but action plans to address any concerns not completed. The service did not audit how many early exits from treatments they had and they did not follow up service users completing treatment. Complaints from service users were not followed up quickly, with most being from those who had exited the treatment unexpectedly. The provider did not have a whistleblowing policy in place and staff could not describe the reporting process if they had concerns about the service.

However

• Doctors prescribed detoxification regimes for people that met guidelines from Drug Misuse and Dependence: UK Guidelines on Clinical Management 2007, and 24 hour on call medical advice was available. Staff monitored withdrawal symptoms using the Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-AR) and the Clinical Opiate Withdrawal Scale (COWS).

• Service users told us that they found the interventions and therapy to be effective and The service had developed effective working relationships with the local GP team. Service users registered with the GP surgery on admission and were seen quickly when there was a need.Therapists who provided group therapy and 1:1 time had regular supervision with the therapist lead.

• We observed caring interactions between all staff and service users. Staff respected service user’s rights to privacy and dignity by providing quiet areas to make phone calls to relatives, or to have 1:1 time with support staff.
• The service actively supported people to maintain relationships with family and friends and provided family support groups every Friday. Support and therapy staff treated service users as partners in their care and treatment. The service ensured active involvement and participation in care planning, evidenced by service user’s participation in care plan reviews.
• The registered manager and chief executive immediately responded to inspectors concerns that staffing at night was inadequate and increased night staffing immediately. We found the management team at Sanctuary Lodge responsive to concerns raised by inspectors, who developed an action plan and schedule to address these following the first inspection.

• Following this inspection we identified that the provider was not meeting Regulation 13; safeguarding service users from abuse and improper treatment, Regulation 17; good governance, Regulation 19; fit and proper persons employed, of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation We carried out enforcement action with the provider and told them to take action to ensure compliance by January 20th 2016. The provider will send us their action plan to meet the regulation and we will check on this at our next inspection.