• Community
  • Community substance misuse service

Luton

Overall: Requires improvement read more about inspection ratings

17-21 Hastings Street, Luton, Bedfordshire, LU1 5BE

Provided and run by:
PCP (Luton) Limited

Latest inspection summary

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Background to this inspection

Updated 1 November 2023

Luton was registered with the Care Quality Commission in April 2015 and is a residential drug and/or alcohol medically monitored detoxification and rehabilitation facility based in Luton, Bedfordshire.

The service includes a seven-bedded detoxification house which is allocated to people undergoing detoxification with 24-hour supervision. On the same site is the treatment centre where clients attend daily for therapy sessions. Where there are a further five on-site bedrooms for people undergoing detoxification.

Thirteen further beds are available for clients in the primary treatment phase of the programme off site; the 8 bedded and 5 bedded houses are not required to be registered with the Care Quality Commission.

At the time of inspection there were 8 people accessing treatment, 3 of these were living in the detoxification house.

The service provides care and treatment for male and female clients. Most clients are self-funded, but the service also takes admissions from local authority drug and alcohol teams.

The service provides ongoing abstinence-based treatment, which focuses on the 12- step programme and also integrates cognitive behavioural therapy, motivational interviewing, psycho-social education and solution focussed therapy.

The service has a registered manager and a nominated individual.

PCP (Luton) Limited is registered to provide:

• treatment of disease, disorder or injury

• accommodation for persons who require treatment for substance misuse.

The Care Quality Commission last carried out a comprehensive inspection of Luton in November 2018 and rated the service as good overall. Safe was rated as requires improvement. Breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified for

regulation 12: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment.

The provider was required to take the following actions:

• The provider must ensure that staff are able to call for assistance if required.

The provider sent their action plan to the Care Quality Commission following the last inspection to address this and during the current inspection we noted all staff had access to personal alarms should they require them.

We carried out this inspection due to concerns relating to observation levels and quality of observations following a death at the service in June 2023.

What people who use the service say

We spoke with 4 people who had used the service. All gave positive feedback about the service and their treatment by staff.

All clients we spoke with were happy with the service. Clients told us that they felt involved in decisions about their care and treatment. Clients said that staff were caring, supportive and helpful. Clients described staff as easy to approach, accessible and responsive to their needs.

Clients we spoke with described how there was a pest control issue and that they had seen mice in the treatment centre.

Clients knew how to complain. Clients felt listened to and that staff were responsive if they felt they were struggling with cravings and needed additional support.

Overall inspection

Requires improvement

Updated 1 November 2023

Our rating of this service went down. We rated it as requires improvement because:

  • The premises were not clean. Staff had not made sure cleaning records were up-to-date and the weekly cleaning checklist was last completed on 23 July 2023. At the time of inspection there was a pest control issue.
  • It was unclear if there were assigned bathroom and toilet facilities for males and females in the detoxification house.
  • Managers did not have audit processes in place to ensure that observations were being carried out in line with the provider’s policy. Staff were not always recording observations in line with the providers policy.
  • Staff did not record comprehensive care plans for each client on the electronic recording system. Staff did not regularly review or update care plans when clients' needs changed.
  • Managers were not adhering to the audit schedule. We could not be assured that staff took part in clinical audits, benchmarking and quality improvement initiatives.
  • Managers had not ensured that staff had received Mental Capacity Act training, staff had not received basic life support training in line with the providers observation policy.
  • Staff did not plan for clients’ discharge in line with the providers admission, treatment planning and discharge policy. Staff did not plan for early unexpected exit from treatment with clients.
  • Managers had not followed the providers recruitment policy.
  • Team meetings were not taking place regularly.

However:

  • The service had enough staff. Staff had received mandatory training and had access to regular supervision and handovers. Staff worked well together as a multidisciplinary team and relevant services outside the organisation. Staff felt positive and proud to work for PCP as an organisation.
  • Staff completed comprehensive assessments with clients on admission. They provided a range of treatments suitable to the needs of the clients. The service offered a full range of treatment groups and activities seven days a week.
  • Nursing staff carried out physical health assessments with clients on admission and regularly thereafter. Any identified needs were appropriately referred. Emergency equipment at both the treatment centre and detoxification house was in date, regularly tested and ready for use.
  • The service offered daily activities and therapies alongside 12-step treatment. Interventions offered included training and work opportunities.

Residential substance misuse services

Requires improvement

Updated 1 November 2023

Our rating of this service went down. We rated it as requires improvement because:

  • The premises were not clean. Staff had not made sure cleaning records were up-to-date and the weekly cleaning checklist was last completed on 23 July 2023. At the time of inspection there was a pest control issue.
  • It was unclear if there were assigned bathroom and toilet facilities for males and females in the detoxification house.
  • Managers did not have audit processes in place to ensure that observations were being carried out in line with the provider’s policy. Staff were not always recording observations in line with the providers policy.
  • Staff did not record comprehensive care plans for each client on the electronic recording system. Staff did not regularly review or update care plans when clients' needs changed.
  • Managers were not adhering to the audit schedule. We could not be assured that staff took part in clinical audits, benchmarking and quality improvement initiatives.
  • Managers had not ensured that staff had received Mental Capacity Act training.
  • Staff did not plan for clients’ discharge in line with the providers admission, treatment planning and discharge policy. Staff did not plan for early unexpected exit from treatment with clients.
  • Managers had not followed the providers recruitment policy.
  • Team meetings were not taking place regularly.

However:

  • The service had enough staff. Staff had received mandatory training and had access to regular supervision and handovers. Staff worked well together as a multidisciplinary team and relevant services outside the organisation. Staff felt positive and proud to work for PCP as an organisation.
  • Staff completed comprehensive assessments with clients on admission. They provided a range of treatments suitable to the needs of the clients. The service offered a full range of treatment groups and activities seven days a week.
  • Nursing staff carried out physical health assessments with clients on admission and regularly thereafter. Any identified needs were appropriately referred. Emergency equipment at both the treatment centre and detoxification house was in date, regularly tested and ready for use.
  • The service offered daily activities and therapies alongside 12-step treatment. Interventions offered included training and work opportunities.

Other CQC inspections of services

Community & mental health inspection reports for Luton can be found at PCP (Luton) Limited. Each report covers findings for one service across multiple locations