This was a desk-top review to assess the service’s compliance with four warning notices issued in February 2018. The notices were issued under Regulation 12 (Safe care and treatment); Regulation 13 (Safeguarding service users from abuse and improper treatment); Regulation 17 (Good governance) and Regulation 18 (Staffing) of the Health and Social Care Act (Regulated Activities) Regulations 2014.

We found that the provider had complied with the actions we told them they must take:

Safe care and treatment

• The provider’s operational policy stated that they would routinely seek client’s medical histories from their GP. They would not accept refusal to consent to share information with a client’s GP without a robust clinical rationale or risk management plan.

• The provider applied clear exclusion criteria that would determine if treatment would be unsuitable due to clinical risk.

• The provider’s procedures included consistent use of risk checklists and use of clear management plans to mitigate identified risks.

• The provider had contingency measures in place to cover clinical duties in an emergency when the sole clinician was unavailable.

• The service had an infection control policy or procedure bespoke to home based provision in place.

Safeguarding service users from abuse and improper treatment

• The service had a robust safeguarding policy that referenced the relevant legal frameworks and good practice guidance.

• The provider had a process in place to record that clients understood the need to use locked boxes for storing medicines used during detoxification.

Good governance

• The clinical governance protocols included systems to assess, monitor and mitigate risk. Incident reporting and learning from incidents was referenced in the service’s policies and procedures.

• The prescribing policy included references to up to date National Institute of Health and Care (NICE) guidance, including those for alcohol detoxification.

• Systems and processes existed for the audit of any aspect of the service being delivered.

• The procedure for transporting clients’ paperwork between the registered location, clients' homes and the home of the registered manager was secure.

Staffing

• Arrangements were in place for supervision or appraisal of the registered manager (clinician) to ensure competency was maintained.

• The registered manager had applied a systematic approach to determine a safe size and composition of the caseload

• Procedures had been put in place to be followed in an emergency to make sure routine work was covered.

We do not currently rate independent standalone substance misuse services. Following the inspection, we took enforcement action against the provider due to concerns about the safety, effectiveness and leadership of the service. We issued the provider with four warning notices under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, for breaches of the following:

• Regulation 12, Safe care and treatment.
• Regulation 13, Safeguarding service users from abuse and improper treatment
• Regulation 17, Good governance
• Regulation 18, Staffing.

Safe care and treatment

• The provider did not routinely seek client’s medical histories from their GP. They accepted clients’ refusal to consent to share information with their GP without a robust clinical rationale or risk management plan.
• The provider did not in their policies and procedures apply clear exclusion criteria that would determine if treatment would be unsuitable due to clinical risk. Whilst the four clients who had received treatment from the service did not show any contra-indications for a home detox or for the medications prescribed, there was no assurance that the provider would not accept an unsuitable referral in the future.
• Care records showed inconsistent use of risk checklists and no evidence of clear management plans to mitigate identified risks.
• The provider had no contingency measures in place to cover clinical duties in an emergency when the sole clinician was unavailable.
• The service did not have an infection control policy or procedure bespoke to

home based provision in place.

Safeguarding service users from abuse and improper treatment

• The service did not have a robust safeguarding policy that referenced the relevant legal frameworks and good practice guidance. The registered manager was not able to clearly describe their responsibilities in relation to safeguarding.
• Care records did not show clear evidence of discussion around confidentiality and consent to share information.
• No process existed for ensuring patients with children were provided locked boxes for drugs during detox.

Good governance

• The clinical governance protocols did not evidence robust systems to assess, monitor and mitigate risk. Incident reporting and learning from incidents were not referenced in the service’s policies and procedures.
• The prescribing policy did not reference up to date NICE guidance and omitted relevant

NICE guidance around alcohol detox.

• No systems and processes existed for the audit of any aspect of the service being delivered.
• Client’s paperwork was not transported securely between the registered location, patients' homes and the home of the Registered Manager.

Staffing

• No arrangement was in place for supervision or appraisal of registered manager (clinician) to ensure competency was maintained. One individual was delivering all aspects of the service without any oversight or supervision of their practice.
• No systematic approach existed to determine a safe size and composition of the

registered managers caseload.

• No procedures existed to be followed in an emergency to make sure routine work was covered.

The provider was told that they must become compliant with these regulations within six weeks of the inspection. Failure by the provider to achieve compliance by this date may result in further enforcement action.

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

• Clients did not receive explicit information about information sharing and the limits of confidentiality.
• Risk management plans did not include plans for unexpected exit from treatment
• Policies and procedures did not cover the Mental Capacity Act. All four clients had the capacity to make their own decisions however assessment paperwork did not clearly document this and no policy existed to respond to a temporary or permanent loss of capacity that could occur during treatment.
• The service complaints policy did not reference duty of candour. This is the duty of all health and social care professionals to be open and honest with patients when something goes wrong, and to apologise when necessary.

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

• Clients received a personalised, home-based service that met their specific needs for flexibility and privacy.
• Clients had the treatment plan and side effects of medication clearly explained to them.
• The clinician assessed and monitored clients’ physical health closely, and routinely carried out health checks during detox.
• The severity of clients’ substance misuse disorder and motivation to undertake a home detox were well assessed by the clinician.
• The medications used for the detox process were those recommended in NICE guidelines and were within recommended safe dosage limits.
• The service was able to offer some psychological therapies as recommended by NICE.
• The clinician had undertaken the appropriate specialist training.
• The clinician demonstrated a compassionate understanding of the impact that the clients’ treatment had on their emotional and social wellbeing.
• The relationship with the clinician and the service itself was commented on positively by the client interviewed and the testimonies in client files.
• All client files showed evidence of the positive involvement of supportive family members.