We do not currently rate independent standalone substance misuse services.

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

• We found in one client record that staff had recognised potential safeguarding concerns and made an appropriate referral to the local authority. However, the registered manager had not submitted a notification to the Care Quality Commission which is a requirement of the Care Quality Commission’s (Registration) Regulations 2009.

We found the following areas of good practice:

• St Anne’s Community Services – Alcohol Services had addressed all of the issues identified at the last inspection and was now meeting Regulations 12 and 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.
• All clients had a risk assessment and risk management plan. Risk assessments were comprehensive and included all risks identified by the original referral. Staff undertook routine ongoing physical health monitoring of all clients admitted to both the detoxification service and the rehabilitation service. Physical health documentation was now stored together with care records. Staff undertook observations and assessments before administering pro re nata (as required) medication in line with the provider’s medication administration policy. The service was now regularly checking the defibrillator in line with the manufacturer’s guidance.
• Systems were now in place to ensure that the registered manager had oversight of compliance rates for mandatory training, supervision and appraisals. The registered manager had implemented a weekly audit which monitored the quality and safety of the service provided. Care records were now of a consistent standard. In cases where the audit had identified issues in care records, there was evidence that the registered manager had taken appropriate action. Cleaning schedules were now being completed regularly.

We do not currently rate independent standalone substance misuse services.

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

• At Anne’s Community Services – Alcohol Services had not addressed all the issues identified at the last inspection and still did not meet Regulations 12 and 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.
• Risk assessments did not include all of the risks identified by the original referral. Clients with identified physical health risks did not have an appropriate risk assessment or plan to manage this risk.
• The service’s process of monitoring the physical healthcare of clients put them at risk because the service missed changes in the physical health of clients whilst they were admitted to the service. This was because when a referrer had not identified a physical health need to the service, then the service would not undertake regular physical health monitoring.
• Staff were not correctly and consistently ensuring that observations and assessments following the administration of ‘pro re nata’ (when required) medications to clients were completed and recorded as per the St Anne’s Alcohol Services medication administration policy
• Managers did not have a system to monitor compliance rates for mandatory training, supervision and appraisals. Local audits had not identified areas of concern that we found with care records, risk assessments and cleaning schedules.

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

• The service had addressed several of the areas of concern identified in the previous inspection. This included sourcing child safeguarding training for staff, completing a risk assessment and plan for responding to emergencies, and introducing a system to monitor equipment to respond to emergencies. The service had explored and introduced alternative medication to support clients with physical health conditions through alcohol withdrawal.
• The service had implemented several of the reported actions that the provider should undertake to improve identified in the previous inspection. This included purchasing a defibrillator and training staff in how to use it, introducing a formal programme of specialist substance misuse training for staff and introducing a statement of recovery produced in partnership with clients.

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

• St Anne’s Alcohol services were not assessing and managing risk effectively. Service risk assessments had not been completed on the use of mixed sex accommodation and client call alarms in the 18 bed residential rehabilitation unit. The medication and equipment required in an emergency, including a defibrillator, and the response time from the emergency services and distance to the nearest accident and emergency had not been risk assessed. Also, the service could not be sure that their equipment was in working order, for example, the staff communication radios. The system to record client risks was unclear and in the care records reviewed, risk assessments and risk management plans were either not present or incomplete. Not all staff were clear about reporting incidents where they felt intimidated as a risk. In addition, risk assessment was not included in the visit’s policy to safeguard children and vulnerable adults.

• Patient physical observations and baseline observations were either not completed or not recorded, or discussed in the staff handover sessions. Similarly, assessments and observations for medication prescribed as the patient required it were either not completed or not documented in line with the services’ policy.

• St Anne’s Alcohol Services had low compliance for some of its mandatory training, including moving and handling patients. This could impact the safety of the staff and the patients. Staff could not all identify child safeguarding risks and concerns, and staff had not received any child-safeguarding training to an appropriate level for their role. There was no formal programme of specialist substance misuse training for the administration of medication, including a schedule of competency assessments or supervised practice.

• Care plans were not holistic and individually tailored to the client’s needs, and clients in the alcohol detoxification service did not get a named nurse on admission. None of the care plans had clear actions, and were not signed and dated by both the client and the staff member. Similarly, the alcohol detox could not be tailored to the client as there was no use of alternative medications.For example where a client had poor liver function. Clients in the alcohol services did not have a discharge plan in place on admission. Staff did not document decision specific mental capacity assessments in the client record where capacity had been a concern. Also, the services did not have any input from a dietician to ensure that they were meeting the nutritional requirements of the clients.

• The mission, vision and values (core principles) were not embedded in St Anne’s Alcohol Services because staff were unclear what they were. Also, there was not a vision or statement of recovery specific to alcohol misuse for staff to embed in their practice, and for clients to work towards. The governance systems established had not operated effectively and were not embedded to assess, monitor and improve the quality and safety of the service provided. In addition, information required by the alcohol services management team to manage the services, for example for supervision, appraisal and training, was not held in one place, and was not accurate.

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

• Staff were caring and treated clients with kindness and respect. The staff had a strong person-centred approach. The service tried to meet the needs of all the clients who used the service and where they were unable to meet a client’s needs, they were transparent with the client and found them alternative service provision in partnership with the community, substance misuse service.

• The psychological therapies, group-based interventions, medications and detox regimes used were evidence based and recommended by the National Institute for Health and Care Excellence. Staff received regular managerial and clinical supervision, and completed annual appraisals. The service completed a number of outcome tools to demonstrate that clients were making progress and meeting their goals. The alcohol services outcomes demonstrated that clients were making changes and leaving treatment having met their goals.

• The environment at St Anne’s Alcohol Services was clean and well maintained, including the outside space. The services were responsive in their approach with clients. Clients had a pre-admission assessment within 10 days of being referred to the service and the usual wait time to access the alcohol services was 11 days from the pre-admission assessment to admission for both the alcohol detoxification service and the residential rehabilitation service. Clients had also been admitted immediately following the pre-admission assessment where this had been required. The doctor saw clients in the alcohol detoxification service immediately on admission. Also, St Anne’s Alcohol Services had been proactive in taking action to reduce their waits to enter the service and improve the service for the clients.

• St Anne’s Alcohol Services were committed to improving the quality of treatment for clients, and the treatment outcomes, through their involvement in national research and projects. Staff, clients, relatives and carers felt able to feedback into the planning, delivery and development of the service. All staff told us that the service manager was approachable and supportive. They felt confident in being able to approach them with concerns without fear of victimisation. Lessons learned from incidents and complaints or compliments were also used to develop and improve the service.

When we visited St Anne’s Community Alcohol Services in August 2013 we found that arrangements for the storage and recording of medicines were unsatisfactory. When we revisited the service we found the provider had taken action and improved arrangements for the storage of medicines and the standards of recording. We found people were protected against the risks associated with the use of medicines.

We spoke with three people who used the service. They said they had been given information about their care and treatment. Their rehabilitation or detoxification programme had been explained to them and they had been given time to think before giving their consent. People said, “They tell you exactly what will happen” and “They discuss everything with us.”

People who used the service had individual care and treatment plans. The plans included a full assessment of their needs and an assessment of their motivation and expectations in terms of their use of alcohol. People had agreed individual goals or outcomes for their programme. People said the service had, “Taught me ways of managing cravings” and “Techniques on how to avoid alcohol.”

There were appropriate arrangements for obtaining, handling, safekeeping and dispensing of medicines. However, recording of the administration of medicines was not always accurate.

Staff were well supported and felt valued. They received appropriate professional development. They were encouraged and supported to obtain further relevant qualifications. Staff received regular individual and group supervision. One said they found the group supervision meetings particularly useful. They said staff discussed challenges they had dealt with and also shared good practice.

The provider regularly assessed the quality and performance of the service. Comments, concerns and complaints about the service were reviewed acted upon to improve the service.

People we spoke with said they were very satisfied with the care and support they had received during their stay. One person discussed their treatment programme and what they had achieved at each stage. They said, “The training programme has been beneficial and my confidence has escalated. I’ve had help in areas such as finding volunteer jobs. Everything is well co-ordinated. They have put the building blocks in place. It’s nice to be back where I am.” Another person said, “This is the best thing I’ve ever done. I feel 110% better and have more confidence. It’s well organised, well run and everyone knows what they are doing.”

People who used the service told us they could express their views and were involved in making decisions about their lives. One person who used the service said, “The programme is structured but works well, we get all the information so know what is happening next. Even when people are reluctant the staff are really good and help them.” Another person said, “We get good support from staff and each other to talk things through and work out what is best.”

People told us that as they progressed through the treatment plan they built up their level of confidence and took more responsibility for their care in preparation for their discharge.

People who used the service told us there were enough staff working at the service and they had the right skills and experience. One person said, “The staff provided support sessions about confidence building, alcohol awareness, managing my money and other areas I needed support with. They have helped me a lot.” Another person said, “The staff are always available, helpful and have a good rapport with everyone.”

Staff told us people received good care and treatment. They said people received individual support with their treatment programme and effective systems were in place to make sure other agencies and professionals were involved when appropriate. They said every person had a clear treatment plan which was based on a structured programme and assessed throughout the rehabilitation period. Staff said they had received training to understand how to meet people’s specialist needs.