09 November 2016
During a routine inspection
We do not currently rate independent standalone substance misuse services.
The location was registered to provide accommodation for people requiring treatment for substance misuse.
This was an announced comprehensive inspection. We also looked again at issues identified at a previous inspection.
Following the last inspection in January 2016, we issued requirement notices relating to breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
The breaches were in relation to:
- Regulation 5: Fit and proper persons: directors
- Regulation 12: Safe care and treatment
- Regulation 17: Good governance
- Regulation 18: Staffing
At this inspection, we assessed whether the service provider had made improvements to the issues we identified in the requirement notices. We found that the provider had made the improvements and had met the requirement notices.
At the last inspection in January 2016, we also found areas that the provider should take steps to improve. These were:
- The provider should ensure that staff members are not line managed by a person to whom they are related.
- The provider should ensure complaints relating to family members are investigated independently.
- The provider should ensure complaints information is accurate and appropriate.
- The provider should ensure that staff have a clear understanding of the principles of the duty of candour.
- The provider should ensure that they are only registered for regulated activities that they provide.
During this inspection we were assured by looking at records and speaking with staff on duty that the provider had taken steps to ensure that these areas had been addressed.
We found the following areas of good practice:
- The environment was very clean, well maintained, welcoming and comfortable.
- Staff managed risk effectively. They identified risks for clients on admission. All clients had detailed risk management plans and staff reviewed the risks regularly according to the level of risk.
- Staff had a good understanding of the duty of candour.
- Clients were involved in decisions about their care and the service. There were agreed house rules and a behavioural code of conduct.
- Staff carried out assessments before clients were admitted to ensure that the service could meet their individual needs.
- There was a structured programme of care, therapy and activities. Discharge planning included an aftercare package to support clients following rehabilitation.
- Care plans were recovery focused. They were comprehensive and detailed. In the records we examined, it was clear what the client’s goals were and how they would achieve them. The service and clients reviewed the care plans regularly together.
- Care and treatment was underpinned by best practice. Clients had access to psychosocial therapies, group sessions and individual one to one sessions with a counsellor.
- Staff worked with clients to help them develop the skills they needed to sustain their recovery and maintain their independence when they returned to the community.
- Staff established therapeutic relationships with clients and involved them in their care.
- Staff treated clients with respect and kindness and supported them throughout their stay.
- There was a structured programme for staff supervision and appraisal of work performance.
- Staff we spoke with were highly motivated in their work and told us they felt very well supported by senior management. There was an open and transparent culture. Staff told us they felt comfortable raising any concerns or issues.
- Staff had a good understanding of the statutory principles of the Mental Capacity Act 2005. The provider had a Mental Capacity Act policy to provide guidance for staff.
- There were effective systems and processes to ensure that the provider complied with the fit and proper person requirements.