14 - 15 December 2015
During a routine inspection
We do not currently rate independent standalone substance misuse services.
We found the following issues that need to improve:
• The service needs to evidence it uses a clinical and social governance framework that would monitor and review learning from audits and incidents.
• There had been one serious incident in the previous 12 months. We were concerned that when speaking to staff members they were not able to identify any learning in relation to the incident. No learning had been identified or actions taken to prevent a similar occurrence.
• Medication audits completed identified numerous errors in the dispensing of medication. The staff team had recorded no learning although additional training had been provided.
• The staff team did not plan for individual client’s early or unexpected exit from treatment. The client within the service did not have a care plan for early or unexpected exit. Generic information packs were available which contained helpline numbers and relapse prevention advice. There was general information available to clients on the loss of tolerance and increased risk of overdose. This did not meet individual client risks.
• The service had identified potential exclusion criteria. These included convictions for arson, sexual offences, or serious violence. Staff told us that the final decision was the managers and the providers and they agreed admission on an individual basis. If the issues were historic, they may not be a barrier to accessing the service. We were concerned that if exclusion criteria were not fully applied this could have presented a risk to other clients and / or their children.
• Records checked including client records, medication administration records, team meeting minutes, and staff supervision records did not evidence actions the service said it had taken. Not all records were completed in a timely manner.
However, we also found the following areas of good practice:
• The service operated with permanent staff. There was no use of agency or bank staff. Staff were familiar with the service and the clients.
• Mandatory training was completed. Training records demonstrated staff were up to date.
• Staff were respectful, relaxed, and responsive to requests made of them. Staff provided practical and emotional support.
• Clients were involved in the planning of their care. They were encouraged to take responsibility for their own recovery.
• There was a regular activity programme available over seven days. The programme provided a range of activities to meet needs. Staff provided religious based activities on a daily basis, which were a part of the therapeutic programme.
• Staff provided group sessions, one to one’s and counselling.
• Clients current and past spoke extremely positively about the treatment programme. They identified positive staff attitudes.
• Staff members had a clear understanding of the vision and values of the service.
• Staff felt they were providing a worthwhile service. They enjoyed their jobs and morale was good.