CQC rates Essex substance misuse service inadequate and places it in special measures

Published: 18 June 2021 Page last updated: 18 June 2021
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The Care Quality Commission (CQC) has rated a Chelmsford alcohol and drug addiction service inadequate and placed it in special measures, after it found shortfalls in measures to ensure patient safety due to poor leadership.

CQC inspected PCP Chelmsford, run by PCP (Luton) Limited, in March and April.

The service was previously rated good. In addition to now being rated inadequate and placed in special measures, CQC requires the service to obtain its written permission before admitting patients for medical detoxification.

Stuart Dunn, CQC head of inspection for mental health and community services, said:

“We were not assured PCP Chelmsford was taking all reasonable steps to protect people from avoidable harm.

“Medicines were not always prescribed according to guidelines and basic measures to prevent the spread of COVID-19, such as wearing facemasks and sanitising hands, were not implemented.

“We also found patient records and risk assessments were not comprehensive, making it hard to track patient progress or escalate problems, and gaps in staff training.

“Behind these issues was a lack of oversight from the service’s leaders. They did not have a good grasp of the issues it faced or demonstrate that they had the knowledge and capability to lead effectively.

“However, all the patients we spoke to said staff treated them with kindness and compassion. They also told us staff involved them in decisions about their care.

“We are monitoring the service closely and will take further action to protect people if we are not assured care is being delivered safely.”

Inspectors found PCP Chelmsford’s leaders were detached and failed to capture or embed learning following incidents. They did not have a good understanding of the issues their service faced, which impaired the quality and safety of care its patients received.

People’s safety was risked because medicines were not always prescribed within guidelines. This issue was worsened because patient records were not completed with enough detail.

Infection prevention and control was poor as staff did not always use face masks and hand sanitiser appropriately, or screen visitors to the premises for COVID-19 symptoms.

However, patients spoke positively of their interactions with staff. They described these as kind and respectful, and inspectors were assured people’s dignity was being maintained.

As the service is in special measures, it will be inspected again within six months. If there is insufficient improvement, CQC will use its enforcement powers further to protect patients from the risk of harm and hold the service’s leaders to account.

CQC has also prevented the service from admitting patients for medical detoxification without its written permission until further notice.

Following the inspection, CQC told PCP (Luton) Limited that it must make several improvements at PCP Chelmsford, including:

  • Following all guidelines to protect people from COVID-19
  • Managing medication and delivering medical detoxification safely, in line with national guidance
  • Regularly checking all medical equipment to ensure it is working correctly
  • Reporting and investigating incidents in line with policies
  • Implementing robust governance processes to monitor the service’s effectiveness
  • Responding to and investigating complaints, in line with the duty of candour
  • Ensuring a working system to record and monitor risks.

Full details of the inspection are given in the report published on our website.

For enquiries about this press release please email regional.engagement@cqc.org.uk.

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About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.