Archived: Cranstoun - Trelawn House

Updated 14 July 2017

Cranstoun – Trelawn House provides a residential rehabilitation service for people who have substance misuse problems. The service can accommodate 15 clients. At the time of our inspection, there were nine clients in the service.

The service received referrals from statutory agencies from inside and outside of London. Different local authorities funded clients in the service on an individual client basis.

Cranstoun – Trelawn House is registered to provide:

Accommodation for persons who require treatment for substance misuse.

There was a registered manager in post at the time of the inspection.

The service was last inspected between the 20 and 22 September 2016. The inspection in September 2016 was an announced comprehensive inspection and part of our national programme of inspections. We found that there were concerns about the safety of the service and issued four warning notices. We also issued a number of requirement notices, which the provider was required to address.

Updated 14 July 2017

We do not currently rate independent standalone substance misuse services.

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

• At the last inspection in September 2016, we identified that staff were not always completing client’s risk information appropriately or in enough detail. During this inspection, we found that the quality of risk assessments and management plans was inconsistent.

• Clients’ risk assessments and care plans did not always identify risks associated with clients’ physical health. Care plans did not always specify how best to support clients with complex physical health needs.

• After the service had been inspected in September 2016, the provider had undertaken a service risk assessment in response to our findings. However, the provider had not reviewed the service’s risk assessment since December 2016.

• The provider had identified a range of formal audits that needed to be undertaken to ensure that the quality and safety of the service was monitored. The provider had not fully implemented the schedule of audits.

• The service was not routinely using early unplanned exit plans for clients. Clients were not being given information as to how to minimise the risk of overdose should they decide to leave treatment early. Clients who have recently undergone alcohol or drug detoxification are at increased risk of overdose.

• Staff were not having regular documented supervision. This meant that staff did not have regular monthly one to one support in line with the provider’s supervision policy.

• Staff were not routinely monitoring the temperatures in the medicines and food fridges. Staff were not undertaking regular fire drills, routine checks of fire equipment and checks on emergency lighting.

• At the last inspection in September 2016, we found that there were a number of medicine errors in the service that had not been reported or acted upon. During this inspection, we found that there had been 17 medicine errors reported between February 2017 and May 2017. We found that staff had not identified two medicines errors.

However, the service had made some improvements since our last inspection in September 2016. We found the following areas of good practice:

• During the inspection undertaken in September 2016, we found that medicines management was unsafe. Multiple medicine errors had occurred. The service had not assessed staff as competent to dispense medicines. During this inspection, we found that the provider had trained staff in medicines management.

• At the last inspection in September 2016, we noted that staff had a poor understanding of safeguarding adults and children. During this inspection, we found that the provider had trained staff in safeguarding adults and young people. All staff knew how to make safeguarding referrals.

• At the last inspection in September 2016, we found there were low completion rates of mandatory training. During this inspection, we found that the completion rates of mandatory training had improved.

• At the inspection in September 2016, we asked the provider to improve their pre-employment checks. The provider had improved their recruitment processes and there were now procedures in place to ensure that pre-employment checks were completed for new staff.

• When the service was inspected in September 2016, we identified that the provider’s governance processes did not ensure the safety and quality of the service. Since that inspection, the provider had reviewed their governance processes. The new processes were not fully embedded at the time of this most recent inspection, though work had begun on this. The provider had begun the process of reviewing their policies to ensure that they were in line with best practice guidance.

• At the last inspection in September 2016, we found that the service was not reporting all incidents that occurred in the service. During this inspection, we found that the service had acted on the findings of the September 2016 inspection. The service was reporting and reviewing all incidents that happened in the service.

• When we inspected the service in September 2016, we identified that clients’ care plans were not specific or measurable. During this inspection, we found that the service was introducing new care planning documents. The new plans allowed clients to identify specific measurable goals. The process was not fully embedded at the time of this inspection.

• At the last inspection we found that the staff working in the service did not understand the principles of the Mental Capacity Act. During this inspection, we found that the service had acted on the findings of the September 2016 inspection, and had provided staff with training in the Mental Capacity Act.

• When the service was inspected in September 2016, we found that the service was not clean. During this inspection, we found there was regular cleaning of the service. Staff were monitoring the cleanliness of the service.

• At the last inspection in September 2016, we found that food was being stored incorrectly in the fridge. During this recent inspection, we found that the service was now storing food items on the correct shelves in the fridge.

Updated 14 July 2017

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