We did not rate this service.

We undertook this inspection to find out whether Turning Point Croydon had made improvements to their service since our last comprehensive inspection in June 2016.

This was a follow up focussed inspection. We found some areas which the provider needs to improve:

At our last inspection in June 2016, we found that staff were not undertaking appropriate physical health checks for clients using the service. During this inspection we found that the provider had put a number of measures in place to address this issue. These included the implementation of a new physical health screen for clients prior to receiving treatment and support for substance misuse and alcohol detoxification. However, although we saw records of new clients to the service that showed they were receiving this new screen, we also saw records of older clients who had not yet received it. Staff explained that, because of the high number of clients using the service, it would take time to complete the review of all physical health checks.

At our last inspection in June 2016 we found that that staff were not appropriately communicating with clients’ GPs to ensure that the service had all necessary information to safely treat them. During this inspection we found that the provider had put several measures in place to address this issue. These included the implementation of a new system to manage sending letters to GPs. This was supervised by a dedicated administrator and the service had introduced a new letter template. This enabled staff to communicate more effectively with GPs. However, while there was evidence of this new system improving staff communication with GPs in the majority of cases we looked at, we also found two cases where staff had failed to do this.

At our last inspection in June 2016 we found that staff did not always complete risk assessments with sufficient detail to identify the severity of those risks and did not always complete appropriate plans to manage those risks. During this inspection we found that the provider had taken actions to address this problem. These included ensuring all staff had completed risk assessment training and regularly monitoring clients’ risk assessments and management plans to ensure they were fit for purpose and up to date. However, while inspectors found evidence of assessments of risk that were appropriately detailed and up to date, we also found four cases where staff had not updated a client’s risk assessment for many months. Staff explained that, because of the high number of clients using the service, it would take time to complete the review of all their risk assessments and management plans.

Following the inspection in June 2016 we took enforcement action and served a warning notice on the provider. We serve a warning notice where we find evidence that a provider of a registered service is in breach of their legal duties and that these breaches constitute an immediate risk of harm to those who use their service. The notice contains a compliance date by which the provider must address our concerns. We then conduct a follow up inspection within three months of the compliance date to check the provider has done this work. The warning notice we served on the provider of this service had a compliance date of 4 October 2016.

After the current inspection we considered that the provider had addressed all the concerns raised in the warning notice by the required date. However, due to the large number of clients using the service the provider had not yet been able to fully complete all of the changes made and new systems introduced, and staff needed more time to review the care and treatment of all existing clients.

For that reason we issued a requirement notice in respect of the remaining concerns that the provider was in the process of addressing. We issue a requirement notice to a provider of a registered service where we find evidence that they are in breach of regulations, but people using the service are not at immediate risk of harm.The legal requirements that were not being met at the last inspection in June 2016 are detailed at the end of this report. The provider has sent CQC a report that says what action they are going to take to meet these requirements

During the most recent inspection, we also found areas of improved practice:

At our last inspection in June 2016 we found that staff did not always appropriately monitor the physical health or withdrawal symptoms of clients receiving treatment for substance misuse or alcohol detoxification. During this inspection we saw that the provider had put several measures in place to address this, including reminding clinical staff through regular supervision to use appropriate tools to monitor clients’ health and withdrawal during treatment. We reviewed four client records and found that staff were doing this in every case.

We will return at a later date to check that the provider has addressed all areas of concern, including other concerns identified at the inspection in June 2016 for which we issued requirement notices.

These notices were under two different sets of regulations. Firstly, under the Health and Social Care Act (Regulated Activities) Regulations 2014 the notices were given in relation to the following breaches of regulations:

• Regulation 9 (person-centred care)
• Regulation 13 (safeguarding service users from abuse and improper treatment) Regulation 16 (receiving and acting upon complaints)
• Regulation 17 (good governance).

Secondly, we issued a requirement notice for the following breach of Care Quality Commission (Registration) Regulations 2009:

• Regulation 18 (notification of other incidents)

We do not currently rate independent standalone substance misuse services.

We undertook this unannounced focussed, follow up inspection to find out whether Turning Point Croydon had made improvements since the previous inspections in June and November 2016.

Following the June 2016 inspection, the provider was served a warning notice for not providing safe care and treatment, and six requirement notices for breaches of regulation.

We told the provider that they must improve on the following areas:

• The provider must ensure that potential risks to clients and others are appropriately assessed. Clients must have risk management plans addressing identified potential risks.

• The provider must ensure that staff are able to identify all clients at risk of abuse and that appropriate action is taken. The provider must ensure all children at risk of abuse are identified and appropriate action is taken.

• The provider must ensure that a physical examination takes place before commencing clients’ treatment.

• The provider must ensure that clients having community alcohol detoxification have their withdrawal symptoms assessed consistently.

• The provider must ensure that all complaints made about the service are investigated. People who complain must receive a written response including how they can appeal against the complaint response.

• The provider must ensure that all clients have a comprehensive, detailed, assessment. Assessments must identify client’s religious and cultural needs.

• The provider must ensure that all medical devices are calibrated in accordance with best practice.

• The provider must ensure that all incidents are reported and recorded. The provider must ensure that all incidents which should be notified to the Care Quality Commission are notified, without delay.

• The provider must ensure a system is operate effectively to monitor the quality of assessments, risk assessments and risk management plans.

At the November 2016 inspection, we found that the provider had made improvements and had met the warning notice requirements. Whilst the service had made improvements to areas of practice, the inspection found that further improvements were required and systems needed embedding into everyday practice. The provider was re-issued the same requirement notices to ensure that improvements continued.

At the January 2018 inspection, we found the following areas of improvements.

• The provider had significantly improved on the quality of client risk assessments. Clients received a comprehensive risk assessment and potential risks were minimised. This included communication with clients’ individual GPs, risk assessment of clients who drove a vehicle, and assessment of clients who were vulnerable to financial and emotional abuse, or whose children were potentially at risk.

• When required staff completed recognised withdrawal tools such as COWS (clinical opiate withdrawal scale) and CIWA-Ar (the clinical institute withdrawal assessment for alcohol) prior to and during treatment.

• The quality of initial assessments had improved. Clients received a detailed initial assessment which included an assessment of a clients’ health and wellbeing, including physical and mental health history and cultural or religious needs.

• Clients received regular comprehensive medical reviews. The quality of assessments had improved.

• The monitoring of physical health had improved. Clients received a thorough and comprehensive physical health assessment prior to and during treatment.

• Staff regularly reported all types of incidents including prescription printing issues. We saw an example of the service reporting an incident that related to a client but had been caused by another service provider.

• The complaints system had improved and complaints were appropriately managed in accordance with the provider’s complaints policy.

• The provider ensured that they routinely reported notifiable incidents to the Care Quality Commission (CQC).

• Client records reflected that clients had been assessed for whether they wished for their families or carers to be involved in their care and treatment.

• The provider had ensured that clinical equipment had been serviced, including the glucose equipment, blood pressure monitoring machine and weighing scales.

• Staff ensured sharps bins were completed and red bags were available in the event of a spillage contaminated with bodily fluids.

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

• Although the provider carried out regular caseload reviews of clients receiving treatment, the recent caseload review in December 2017 demonstrated that 11% of clients receiving treatment did not have an up to date risk assessment in place. Prior to the January 2018 inspection, the provider had plans in place to address the outstanding number of incomplete risk assessments. For example, for three hours per week the service closed to allow staff the opportunity to complete administrative work.

• At the January 2018 inspection, most clients had up to date care plans. However, two out of 16 care plans were either not available or had not been updated since May 2017. There was a risk that without a care plan or an updated care plan, there was no record in place to demonstrate how clients were supported.