5th-6th April 2016
During a routine inspection
We do not currently rate independent standalone substance misuse services.
We found the following areas of good practice:
Safe
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Communal areas that people used were all clean, comfortable and well maintained. Bedrooms were well maintained and furniture was in a good state of repair.
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A new training matrix had been developed for staff.
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Risk assessments for all clients were completed regarding the use of cleaning products.
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The health and safety risk assessment for the building was updated on a weekly basis.
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Electrical safety testing, legionella and gas safety checks had all been completed within appropriate time frames.
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All staff had first aid training.
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Clients could access a range of treatments and support and there were enough staff on duty to provide those treatments.
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Appropriate pre-employment checks had been completed for all staff.
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Care records had a comprehensive assessment, up to date care plan and risk assessment with plans in place for unexpected discharge from the service.
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Medication administration records were up to date, well organised and clearly documented which medications had been prescribed.
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Staff were offered a full debrief after incidents and we saw evidence in team meetings that lessons learned from incidents were fed back to the team.
Effective
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Care records had a personalised recovery plan in place. All clients had been given a copy of their care plan.
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Groups were well facilitated and well structured.
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Staff meetings were well attended and staff were able to discuss any issues.
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There were good links with local recovery communities.
Caring
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Staff treated clients with kindness dignity and respect.
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Clients were actively involved in their care and were able to raise any issues in community meetings.
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Carers were invited to a monthly friends and family meeting where they were encouraged to give feedback and could be supported on an individual basis.
Responsive
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All clients were given a copy of the residents handbook upon admission into the service.
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We saw holistic needs assessments that had been undertaken for all the clients’ records we looked at.
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Discharge planning was documented in care plans and clients attended moving on groups
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Clients engaged in community activities to prepare them for discharge.
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There was a weekly support group for ex-clients.
Well led
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Sickness and absence rates were low at 3%.
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Staff felt confident to raise their concerns to managers.
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Morale was good and the team worked well together
However, we also found the following issues that the service provider needs to improve:
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Clients and staff used a vestibule area to smoke and this filtered into the main building potentially affecting the health of others.
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Medication checked in after delivery by the pharmacist was not itemised.
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Staff were not aware of the Duty of Candour
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Staff were not aware of best practice legislation or guidelines.
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Staff were receiving regular supervision but this was not in line with the supervision policy.
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Staff had not received Mental Capacity Act (MCA) training and were not aware of the principles of the MCA.
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Some parts of the building were not accessible to people using wheelchairs or who had other types of restricted mobility.
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Clients were not aware that forms were available if they wanted to provide written feedback to staff.
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We found that the service had not developed some policies. These included the Duty of Candour and Mental Capacity Act 2005 policies. We found that some policies were out of date or had no review date. These included the supervision policy, lone worker policy and whistleblowing policy.