We rated Fleming House good because:

• The service had enough staff to safely meet client’s needs. Staff at all levels of the organisation had appropriate skills, knowledge, and experience to provide the right care and treatment.

• The service had clearly defined and embedded processes to keep people safe. Staff understood their responsibility to report incidents and managers took actions to improve safety.

• The service had clear and robust policies in place for safeguarding adults and children. Staff received safeguarding training. Staff identified safeguarding concerns and took steps to prevent abuse from occurring. Management had established links with the local authorities safeguarding team and reported concerns.

• Staff received training in the Mental Capacity Act 2005 and applied this in practice.

• The service took a holistic approach to assessing, planning and delivering care. Clients received a comprehensive assessment before entering treatment. Clients personal preferences, strengths and goals were reflected in care plans. Clients were involved in developing their own risk assessment and crisis plans. Staff supported clients to develop timely, holistic and personalised discharge plans. Clients records were clear, up to date and were accessible for staff.

• The service provided care and treatment in line with national guidance. The service provided treatment for clients, which included medication, psychological therapies, and occupational activities intended to help patients acquire living skills. There were a range of activities for patients to take part in including gardening, games, acupuncture, bowling, and classes in computer skills and digital photography.

• The service monitored and reported client treatment outcomes. Staff used structured assessment tools to regularly review client’s recovery and needs.

• The service sought to work collaboratively with other providers and agencies to promote high quality care and positive treatment outcomes. The service exchanged knowledge and skills with other providers. The service worked in collaboration with other providers to develop a ‘treatment loop’ which allowed clients to continue their recovery at another centre after breaching specific treatment requirements.

• Staff displayed positive attitudes and behaviours when interacting with clients. Clients described staff as approachable and helpful. The service sought to accommodate client’s preferences and needs, such as dietary, cultural, religious, communication, and needs arising from disability.

• The service sought feedback from people using its service and had a clear policy for managing complaints. Managers promptly investigated complaints, apologising and acting on them where required. Management involved clients in resolving complaints.

• The service had suitable premises and equipment and looked after them well. The premises provided separate floors of accommodation for male and female clients. The premises provided a range of private and communal areas for socialising, individual and group therapies. Clients had access to a garden and spaces to meet visitors.

• The service had a manager in post with the right skills, knowledge and experience who was approachable and visible for staff and clients.

• The service had governance systems that collected, analysed and used information to monitor and improve care. The service had effective systems for identifying and managing risk.

However:

• The service maintained thorough cleaning records for the environment but held no cleaning records for medical equipment, such as sphygmomanometer, also known as a blood pressure meter. This is posed a potential infection control risk. However, on visible inspection these devices appeared clean and staff told us they cleaned them regularly.

• The service was not using disposable breathalyser mouthpieces. However, the service was sterilising breathalyser mouthpieces between use.

• The services ligature risk assessments identified areas of concern but did not adequately document how risks were mitigated or removed.

• The service did not have a written procedure for managing bathing safety for clients undergoing detox. Clients who are detoxing from alcohol can be at higher risk of experiencing seizures.

• The service did not maintain records of whether clients had been offered copies of their care plans.

We do not currently rate independent standalone substance misuse services.

Our last comprehensive inspection of Fleming House was in December 2016. At that inspection, we issued three requirement notices. Issuing a requirement notice notifies a provider that they are in breach of legal requirements and must take steps to improve care standards.

On 10 May 2018 we undertook an unannounced, focused inspection to see whether the provider had made the required changes and found the following improvements had taken place:.

• Following the last inspection in 2016, we told the provider they must ensure they assess clients referred for alcohol detoxification to ensure they are suitable for the service. At this inspection, we found that the provider had clear admissions criteria and only admitted clients suitable for the services and treatment provided.
• Following the last inspection in 2016, we told the provider that they must ensure clients had access to emergency medication and that medication to manage seizures was prescribed for clients who required it. At this inspection, we found that clients did have access to emergency medication. The service only admitted clients with epilepsy only when their condition was stabilised with medication. The service does not admit any clients with a history of alcohol withdrawal seizures at all.
• Following the last inspection in 2016, we told the provider they must ensure staff maintain the kitchen to an appropriate standard of hygiene. Staff working in the kitchen must have the appropriate training and supervision. At this inspection, we found that the kitchen was clean and tidy and there were plans in place to ensure all staff were trained with the appropriate skills required.
• Following the last inspection in 2016, we told the provider they must ensure all actions they have identified in risk assessments to mitigate risk to clients are completed. At this inspection, we found that there was a comprehensive environmental risk assessment in place, which was updated and reviewed regularly.
• Following the last inspection in 2016, we told the provider they must report all safeguarding issues to the appropriate safeguarding team as soon as they became aware of them and to notify the Care Quality Commission of incidents as required. At this inspection, we found that the provider had an effective safeguarding policy in place and that referrals were being made to the local safeguarding authorities and the Care Quality Commission.
• Following the last inspection in 2016, we told the provider they must ensure they report all incidents in line with their incident policy and that they monitor incidents and disseminate any lessons learnt to the wider team. The provider must ensure all relevant information is reported to the fortnightly management team meeting. At this inspection, we found the provider had a good incident reporting policy in place and this was being followed by staff. There was an incident log, and learning and feedback was disseminated through staff meetings and handovers.

We met with five people who used the service, a relative, staff and managers of the service.

People were wholly positive about their experience. Some people had been through treatment programmes in the past and one person described the care and support at Fleming House as “got to be the best” and another said it was the “first one that has got me clean”.

People we met with were at differing stages of their recovery but all felt the therapeutic content of the treatment programme was right for them. People felt respected by staff and appreciated that staff reliably delivered on their agreed treatment and support plan.

We saw that each person had signed a range of agreements either prior to or on admission and staff told us they periodically reviewed these throughout the programme. People were aware of their responsibilities and also of their rights to continue with the programme or not.

Staff appeared motivated and said they felt both valued and supported. They were particularly appreciative of the way the staff team worked together and of the opportunities for supervision and training.

People felt safe and staff demonstrated a good understanding of their responsibilities in relation to safeguarding.

Staff received the training and support appropriate to their role which enabled them to meet needs of the young people using the service.

The quality of the service provided was monitored by an effective quality assurance processes.

We carried out this inspection to follow up compliance actions made as a result of our inspection on 18 June 2013. The provider sent us an action plan to say action had been taken to address the compliance actions and that these were completed by 30 September 2013.

We also looked at the home’s complaints procedure, the discharge procedure and the way that people are informed of the range and limitations of the service it provides. This was as a result of concerns raised with us.

People told us they received information about the home before they moved in. People said they were aware of the complaints procedure and how to use it.

We saw the home has addressed the compliance action regarding staff recruitment.

We saw the home addressed any complaints made although we noted the complaints procedure did not give details of who complainants could go to if they were dissatisfied with the home’s response to complaints.

This was a scheduled inspection but we also looked at two outcome areas where we made compliance actions at the previous inspection of 11 February 2013. The provider sent us an action plan outlining how the home would be addressing compliance actions regarding the home’s medicines procedures and decorative defects in bathrooms and toilets. The action plan said the compliance actions were completed by 20 March 2013. At this inspection we found the home met the compliance action regarding the environment. The home had made a number of improvements to the medicines procedures but we still found there were aspects of the recording and storage of medicines that needed to be to be addressed.

Each of the people we spoke to said they were satisfied with the service they received. People said the 12 week programme was helpful.

People’s needs were assessed before they came into the home. Each person had records of their recovery programme as well as records of counselling sessions and medical needs. People told us they received a copy of their care plan which they had signed to agree to its contents.

We looked at the home’s procedures for the recruitment of newly appointed staff and found that suitable checks were not being carried out.

People said they had opportunities to discuss issues about the home and their individual care. We saw the home also obtained the views of people by the use of survey questionnaires.

We spoke to four people living at the service and to a three staff as well as the manager.

Each of the people we spoke to said they were satisfied with the service they received. People said the 12 week programme had been helpful. One person said, “I have nothing but praise for the place.” People said the staff treated them with respect.

The 12 week programme involved people agreeing to abstain from alcohol and drug use along with restrictions on their daily lives. People said they were in full agreement with this and understood this was needed to help them recover.

People’s needs were assessed before they came into the home. Each person had records of their recovery programme as well as records of counselling sessions and medical needs.

People told us they felt safe at the home.

The home was staffed 24 hours a day by a combination of support staff and counselling staff. People told us there were enough staff on duty and that staff were skilled in helping them. Staff had access to a range of training courses and received supervision.

The home had a combination of shared and single rooms. We found communal bathrooms were in need of repair.

The home’s medication procedures were in need of attention. Accurate records were not maintained of medication coming into the home or of medications administered to people.

People said they were aware of the complaints procedure. We saw records were maintained of how complaints were dealt with.

We do not currently rate independent standalone substance misuse services.

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

• The provider had not completed actions identified in its ligature point (a ligature point is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation. Ligature points include shower rails, coat hooks, pipes and radiators, bedsteads, window and door frames, ceiling fittings, handles, hinges and closures) risk assessment. Risk assessments had not identified all significant risk to ensure clients had a safe detoxification treatment. The provider did not have appropriate plans in place to manage seizures.

• Staff were not following policies relating to the safe administration of medication, safeguarding vulnerable adults and children and incident reporting.

• Detoxification did not always follow national institute for clinical excellence (NICE) guidelines and staff had no specialist training.

• The provider did not have effective arrangements in place to protect vulnerable women in an area containing bedrooms for both men and women.

• The kitchen was dirty and not maintained to a suitable standard.

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

• All staff had completed mandatory training.

• Regular fire testing and drills took place.

• Staff explained the reasons for any restrictions and the clients we spoke to understood them and were happy to follow them.

• The service used nationally recognised opiate withdrawal scales, to assess the effects of clients’ withdrawal symptoms and arrange for medication to relieve them.

• Staff dealt with concerns raised by clients promptly.

• Staff collected clients from their own home when admission was needed.

• The provider offered clients who had been discharged the opportunity to attend some less formal groups following their discharge, this was provided at no extra cost.

• The service had developed the “treatment loop” to enable motivated clients to continue treatment at a different service if they were unable to continue at Fleming house due to using substances or breaking other requirements and rules of staying at Fleming house.