Due to the safety issues identified on this inspection the Care Quality Commission took immediate enforcement action to suspend the provider’s registration. This meant that the service was not allowed to provide care and treatment to clients until significant improvements had been made. A final version of this report, which we will publish in due course, will include full information about our regulatory response to the concerns we have described.
We issued a Notice of Decision to suspend registration because we were not assured that staff had the qualifications, competence, skills and experience to care for clients safely. Support workers, who were caring for people in alcohol withdrawal were not competent, skilled or experienced in either the assessment and monitoring of withdrawal symptoms or in responding to potentially very serious physical health side effects. Two clients required admission to emergency acute care following alcohol withdrawal related seizures. Staff were not trained in essential skills to recognise and respond to people’s health deteriorating due to alcohol withdrawal or and had not received other mandatory training.
We were not assured that staff were appropriately qualified. The service did not provide registered nurse staffing 24 hours a day, seven days a week, in line with their Care Quality Commission registration. Agency nurses, when used, did not have the required skills and experience to provide care. There was no clinical leadership in the management team when we inspected on 29 November 2022. We found that in seven of nine staff employment files we reviewed there were no readily available DBS checks or outcomes recorded. We could not find the required two employment references for registered nurses.
We were not assured that there was effective medicines management to ensure clients received safe care and treatment. We found systems were not robust to ensure safe management of medicines and clients were exposed to serious risk of harm. Staff who administered medicines, were not all suitably qualified and competent to administer medicines safely. Staff did not have the formal training to use formal assessment tools to assess the nature and severity of alcohol misuse. Assessment tools to determine the severity of withdrawal symptoms were not always effectively completed for clients who were detoxifying from alcohol. This potentially increases the risk of adverse physical effects from alcohol detoxification, such as seizures. Staff had failed to obtain clinical guidance from a suitable person with the necessary skills and competence when a client was not available for all of their first day detoxification doses. We found that clients did not always receive their full detoxification regime. There were no emergency medicines available for staff to use in an emergency such as a seizure, emergency medicine could stop the seizures or no appropriate risk assessment to assess which emergency medicines staff may or may not need in this service.
We rated it as inadequate because:
- The service did not provide safe care. The clinical premises where clients were seen were not safe and clean. Managers had not identified all environmental, ligature and fire risks or taken action to mitigate them. Staff did not clean the environment in line with infection prevention and control procedures and follow universal masking procedures during a covid outbreak.
- Premises were not suitable for the client group and managers had not implemented processes that reduced risk. The service provided mixed sex accommodation and did not have enough bathrooms that clients could safely access. Clients were allocated to bedrooms without consideration of sexual safety or detoxification side effect risks.
- Maintenance issues were not acted on and resolved quickly. The premises refurbishment had not been fully completed before clients were admitted. There was no oversight of maintenance jobs that needed completed.
- Clinic rooms were not fully equipped, and staff did not check and maintain the equipment they had. There were no emergency equipment or emergency medicines available for staff to use in an emergency such as a seizure; emergency medicine could stop the seizures. There was no appropriate risk assessment to assess which emergency medicines staff may or may not need in this service.
- Managers had not ensured that staff had Basic or Immediate Life Support training, or an emergency first aid trained member of staff always on shift.
- The service did not have enough nursing and medical staff working in the service to keep clients safe 24 hours a day, seven days a week. There was no clinical leadership and staff could not access any medical input when we inspected on the first day. The service had only one part time nurse employed that physically worked on the premises on a part time basis. The registered manager had also contracted an independent nurse prescriber to remotely assess new admissions in evening prior to admissions.
- Managers did not ensure that all staff, including agency staff, had a full induction and understood the service before starting their shift. Agency nurses we spoke with had no prior experience in detoxification or substance misuse services.
- Staff did not receive basic training to keep people safe from avoidable harm. Although some staff had completed statutory training, none of the staff had completed nine of the eleven training courses required to deliver client care. The other two courses had poor training compliance rates and the service. The mandatory training programme was not comprehensive and did not meet the needs of clients and staff. Managers did not provide staff training in the Mental Capacity Act, Clinical Risk Assessment, Medicines Management training or the appropriate level of Safeguarding training.
- Staff did not complete effective risk assessments for each client prior to admission and on arrival. The service did not use a recognised tool in line with best practice, risks were not categorised appropriately, and risk management plans were not created. None of the 11 risk assessments we viewed were signed by a doctor, nurse or manager. Staff did not use tools to assess and screen alcohol harm and dependence or when assessing risk or access to a full GP summary before commencing detox regimes. The service admitted clients even when it was not safe to do so.
- Staff did not follow good practice with respect to safeguarding. Staff did not have training on how to recognise and report abuse and the provider did not act in accordance with its own policy. Staff did not inform the local authority of all safeguarding incidents. Managers did not complete all appropriate employment checks for every staff member working in the service.
- The service did not fully use systems and processes to safely prescribe, administer, record and store medicines. Staff did not regularly review the effects of medicines on each client's mental and physical health. Staff who administered medicines were not all suitably qualified and competent to administer medicines safely. Staff did not always record alcohol assessment scales regularly and clients did not always receive all medicines over the course of their prescribed detoxification.
- The service did not manage client safety incidents well. Most staff did not recognise incidents and report them appropriately. Managers did not investigate incidents or share lessons learned with the whole team. When things went wrong, managers did not apologise and give clients honest information and suitable support.
- Leaders did not have the skills, knowledge and experience to perform their roles. None of the management team had experience in delivering a medically managed detoxification service. None of the managers had clinical experience and managers had not made suitable arrangements to ensure there was clinical leadership and input into the service before admitting clients.
- Organisational data including staff and client records were not stored securely. Care records and staffing data were stored on google shared drive which is not compliant with all data protection regulations.
- Managers had not created a safe and open culture where staff felt supported and valued. Managers did not provide inductions, supervision or regular team meetings. The provider did not have any vision and values that were shared with their staff or applied to the work of their team.
- Leaders had not implemented safe systems and processes to provide safe and good quality care to clients using for the service. Managers did not have access to information to support them with their management role. Managers struggled to locate basic information that was associated with the day to day running of the service. Information was not timely or accurate; it did not identify areas for improvement. We reviewed training and recruitment systems and processes, policies and provider documentation including incident reporting systems that were not accurate, complete or updated. None of the policies we reviewed reflected the care being provided or how the service was run.
However:
- Clients described most staff as nice, lovely or good.
- Clients said that the food provided was of excellent quality and that the service met specialist dietary requirements.
- Clients could contact staff on walkie talkies if they needed assistance during the first few days of detoxification.
- Clients and staff said that most managers were present in the service.
- Support staff updated client progress notes each shift.