Archived: Withersdane

We do not currently rate independent standalone substance misuse services.

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

• During our inspection in August 2016, we found the service in breach of regulation 12 of the Health and Social Care Act 2014 concerning lack of call alarms in client bedrooms. The service had installed an alarm in only one bedroom at the time of our inspection.

• It was part of a requirement notice from our comprehensive inspection that the service conducted regular fire drills and had relied on false alarms to conduct drills. The service had recently commenced fire drills and had conducted their first scheduled drill on 3 July 2017.

• At the comprehensive inspection in August 2016, we found that not all staff were competent to administer emergency medicines. During this inspection, three staff told us they did not feel competent or confident to administer this medicine.

• The service stored emergency medicines including naloxone, epipens and buccal midazolam. Buccal midazolam is a prescription only medicine that only clinical staff who have agreed to work within the terms of a patient group direction can administer. However, we saw that some staff had been trained to administer buccal midazolam who did not meet the legal framework to do so. Inspectors raised this with the clinical manager who acted on this information.

• Rotas reviewed showed that there had been no nursing cover for part or all of 10 of the 14 days between 26 June and 9 July 2017. The rotas recorded that the service had arranged cover for six shifts between 8pm and 8am during this period. However, there was no nurse available for seven shifts between 8am and 8pm and five shifts between 8pm and 8am.  Volunteers from the sober living community were included in night staff numbers. The rotas demonstrated that there were only two health care assistants available after 10pm on four occasions during this period. The Group Clinical Director has confirmed that since the inspection, the service has recruited a nurse and confirmed that there will be three permanent nurses in post from the end of September 2017.

• At the comprehensive inspection in August 2016, we issued a requirement notice that the service should implement a more robust system for incident reporting. During this inspection there was no evidence of a formal process to collate, analyse or share learning from incidents.

• We reviewed 11 prescription and administration charts. Staff had recorded allergies on prescription charts. However, some charts contained a number of administration gaps, which represented missed doses of medicines. This also included medicines which should not be stopped abruptly. Additionally, it was not always possible to tell the reasons for missed doses as staff did not consistently record this information.

• Clinical staff completed a pre admission assessment form and medical assessment for all clients. However, the assessment process did not include questions about children as recommended in the drug misuse and dependence UK guidelines on clinical management and as identified in our report following the comprehensive inspection in August 2016. The assessment process did not formally demonstrate consideration of Wernicke Korsakoff syndrome, which had also been identified at the last inspection. Wernicke’s encephalopathy is a disorder that affects the function of the brain. It usually develops suddenly, often after abrupt and untreated withdrawal from alcohol.

• Some people were self-administering medicines but this did not match the service’s policy.

• Our inspection in August 2016 identified that staff should receive regular one to one performance management meetings. Only two of the staff interviewed during this inspection said that they received regular performance management meetings.

• The service had updated their admission policy to include exclusion criteria since our last inspection. The policy included information about categories of clients that the service would not provide treatment to and actions for staff where there may be concerns that the service could not meet a client’s needs. However, the criteria was basic and did not provide detailed information. For example, it did not include the minimum body mass index for clients with an eating disorder that the service would consider for treatment.

• The service relied on sending information to staff via emails which were not saved on the electronic framework.

• We found that staff had not reported four incidents that required notification to CQC.

• Data provided by the service recorded that six of the 27 volunteers did not have a disclosure barring service check in place.

• After our comprehensive inspection in August 2016, we issued a requirement notice that the service should make sure that their statement of purpose (SOP) contained accurate information. No changes had been made to the SOP reviewed during this inspection.

• The service did not have a Duty of Candour policy. However, since being raised by inspectors, the service was developing a policy.

• However, we also found the following areas of good practice:

• Risk assessments were comprehensive and detailed. The clinical manager reviewed risk assessments and risk management plans to make sure they were accurate and up to date.

• There was an appropriate range of emergency medicines, including oxygen that were within their expiry dates. Staff checked emergency medicines weekly.

• The service had recruited a doctor who was on site during normal working hours. Staff could contact the doctor outside of normal working hours if required.

• We reviewed 14 client records which were comprehensive and detailed. Care plans were individualised and staff regularly reviewed progress with clients. Staff knowledge of clients was good.

• An external pharmacist visited Withersdane every other week to help screen prescription charts and undertake medicines management audits.

• Staff followed the service’s safeguarding policy and knew when a safeguarding referral would be appropriate.

• The clinical manager had introduced guidance of staff responsibilities during a client’s treatment journey.

• The process to audit client files was effective. The clinical manager reviewed all client records to make sure that they were accurate and up to date prior to attending the clinical management meeting.

• We observed a clinical management meeting. The meeting allowed staff to contribute in decisions made about the care of clients.

• We found that the service had acted on the following concerns identified during our inspection in August 2016:

• The service had acted on the requirement that staff must have access to emergency medicines quickly and without delay. The service had increased the set of emergency medicines to two and located them in different site areas to allow staff quick access.

• The service had reviewed the process for staff administering medicines since our last inspection. Staff administered medicines in a dedicated area away from the clinic room to avoid interruption.

• At our inspection in August 2016, we issued a requirement notice that the provider must ensure there were robust systems in place to ensure that client records were up to date and stored appropriately. During this inspection, we saw that this had been addressed.

• At the last inspection we identified that the provider should encourage staff to work more as a multi-disciplinary team. We saw that the provider had created one large office for all staff, to encourage multi-disciplinary working. Staff told us that communication between the three different roles had improved since this office had been introduced.