Updated 1 January 2020
PCP Leicester registered with the Care Quality Commission in December 2014 and is a residential psychosocial drug and alcohol, medically monitored detoxification and rehabilitation facility. It is based in Leicester city centre, Leicestershire. At the time of inspection, the service had a registered manager Rebecca Crutchley, and a nominated individual. They did not have a controlled drugs accountable officer.
The service includes a treatment centre where clients attend daily therapy sessions, and a seven-bedded detoxification house, known as St Stephens for people undergoing detoxification with 24-hour supervision. St Stephens is separately registered with the Care Quality Commission, and although inspected alongside PCP Leicester it has been reported on separately.
PCP Leicester provides ongoing abstinence-based treatment, which focuses on the 12- step programme and integrates cognitive behavioural therapy, motivational interviewing, integrated psychotherapy, psycho-social education and solution focussed therapy.
PCP Leicester is registered with CQC to provide treatment of disease, disorder or injury.
At the time of inspection, seven people were accessing the service for day treatment. The length of stay for clients in treatment was between two and twelve weeks.
The service provides care and treatment for male and female clients. PCP Leicester accepts self-referrals from privately funded individuals and drug and alcohol community teams primarily from the midlands area.
The Care Quality Commission has carried out three inspections in November 2015, March 2017 and July 2018. Following the last inspection, we found the following practices needing action by the provider:
Regulation 17 HSCA 2008 (Regulated Activities) Regulations 2014 Good Governance – Requirement Notice
- Overarching governance of the service was not embedded practice. Management was not monitoring new guidance and policy to ensure it was working. Management was not evaluating and checking their quality improvements for effectiveness. The service did not have targets or key performance indicators. Quality assurance management and performance frameworks were not in place. The risk register was incomplete. Registered managers did not have enough time, authority or autonomy to carry out their duties effectively. Communication between senior management and location managers and staff was not always good. Not all recruitment processes were robust. The provider did not have clear vision and values.
- Poor cleanliness due to lack of monitoring in the communal kitchen area posed risk of infection for staff and clients. Managers had not included blind spots on the environmental risk assessment.
- Management had not completed clinical audits. We did not see any external audit of the processes relating to medicines management and dispensing medication for the three months prior to inspection.
- The medications policy did not reflect amendments to the health and social care regulations or current guidance around medication management. There was no controlled drugs accountable officer for the service, and the provider had not addressed the need to work in partnership with a local pharmacist, or the local controlled drugs accountable officer group.
Furthermore, we asked the provider to consider action in respect of the following:
- The provider should consider harm reduction measures in respect of their practice to accept new referrals on a Friday morning for detoxification.
- The provider should consider inviting new clients to view the accommodation part of their service prior to signing admission agreements.
- The provider should have clear vision and values, to ensure staff and clients know what to expect of the service.
At this inspection we found the provider had or were addressing all the above actions. How the provider addressed the issues is recorded in the detail below.
To be noted: Since writing this report the provider has de-registered this service with the Care Quality Commission. This means the service no longer exists.