We Can Recover CIC

Clinical rooms were not fully equipped, with emergency drugs that staff checked regularly. The service did not follow best practice standards to purchase and maintain equipment. The service did not have a couch in the clinical room, weighing scales or a height measure stadiometer. There was no locked cupboard to store medicines in the clinical room, other than a locked filing cabinet, which did not meet medicine storage guidance.

Although the service had contracted a named GP prescriber, their role and cover arrangements remained unclear. The registered manager could not confirm if the named doctor was acting as an independent doctor or prescribing care and treatment under the regulated activity accommodation for persons who require treatment for substance misuse on behalf of or employed by, We Can Recover CIC. The consulting agreement did not specify what services the doctor would be providing. This did not include how the doctor had oversight of the information for the referral and assessment process for a client. There was no clearly defined role for the doctor in the referral, assessment and admission process the registered manager described, and the registered manager and assistant manager clarified the policy and process had not yet been defined or completed. The service could not clarify what cover arrangements were in place for the prescribing and monitoring of medication when the named GP was not available. It was unclear who would be responsible for the medical/clinical oversight and personal development of staff at We Can Recover who have not previously worked within a residential substance misuse service. There was still no on call policy and procedure in place on 23 February 2023, with no reference to the named doctor’s role, responsibilities, and medical oversight.

The service did not have enough nursing and medical staff, who had completed basic training to keep people safe from avoidable harm. Although the provider had recruited nursing staff, most lacked previous experience in substance misuse. Arrangements to cover gaps in staffing were not formalised and there was not a clear clinical escalation route for queries out of hours. The arrangements on how registered nurses would be deployed over a 24 hour basis could not be determined as the provider could only assure the inspectors, they would admit clients on a risk based phased approach, until they had a service level agreement agreed with the named GP, and the admission team could accept clients. Managers did not use a safe staffing tool to determine staffing numbers. There was still no clinical escalation route out of hours for staff to access a named doctor. The on-call protocol had not been finalised at the time of the inspection.

Staff were not provided with the skills needed to safely deliver care to clients in the service. Training records were updated to reflect staff had completed mandatory training, but there were still gaps in the nursing and support staff completion. The mandatory training programme was not comprehensive, did not meet the needs of clients and staff, and staff had not completed all the expected areas of mandatory training. Relevant training, indicated on the suspension notice, had not been arranged for ligature risk management. Role specific training had not been completed by nursing and support staff. Only one of the four registered nurses was recorded as completing basic life support on the provider training matrix version 6. None of the staff on the training matrix had completed managing challenging behaviour, signs of withdrawal, understanding recovery and supporting clients through their treatment. An administrator and support worker were the only two staff who had completed training on the Mental Capacity Act 2005. Having this training and knowledge is essential for staff working in a detoxification and rehabilitation substance misuse service. Managers did not ensure that staff had access to all the training on the service training matrix, necessary for their role, as there were still identified gaps in training to support clients during their recovery. The latest version of the training matrix identified role specific training that was indicated on the suspension notice had either not taken place or been completed at the time of this inspection and remained outstanding.

The admission process was unsafe, in that staff who screened client’s admission and risks were not trained to do so. The process for reviewing risk prior to admission was unclear. Staff screening client’s admission had not completed all the role specific training required to fulfil their role. The service had not developed effective systems and processes to review risk prior to admission. They did not assess and manage risks to clients well. The service remained unclear on the effective systems and processes to review risk prior to admission, and it was unclear if there was a multidisciplinary approach to admission. The service had not confirmed that the named GP prescriber would have access to client’s summary care records or current blood results when assessing admissions. The service was unable to describe effective systems and processes to review risk prior to admission and it was unclear what service the named GP would provide and when it would be provided. We were not confident the named GP prescriber would have access to client’s summary records or current blood results when assessing new admissions, without a service level agreement. There was no signed or dated service level agreement that provided the information we required. We were not assured the service recognised the need for medical oversight and assurance.

Training records provided recorded only two of the four registered nurses had completed medicine administration training. The process around clinical oversight and supervision of registered nurses in medicine management remained unclear. The service had not implemented a safe system and process to safely prescribe and store medicines. The registered manager could not provide additional clarity on the prescribing of emergency medicines for alcohol detoxification, until a service level agreement had been discussed with the named GP. Managers were unable to provide assurance that suitably qualified staff would be able to review client’s medicines regularly and provide advice to clients and carers about their medicines. There were no cover arrangements in place for when the named GP was not available to prescribe or monitor medication. The service could also not clarify the arrangements for the assessment, planning and delivery of care and treatment of clients being admitted to the service by a medical or clinical practitioner or arrangements to respond appropriately and in good time to client’s changing needs, so medicines are administered accurately, in accordance with any prescriber instructions and at suitable times. The service could not clarify the arrangements for clients storing, accessing, and managing their own prescribed medicines based on risk assessments that balance their needs, safety, rights, and preferences. The service kept no emergency medicines and the service had amended the policy on the use of emergency medicines to clarify which emergency medicines clients would have to bring with them as part of the pre-admission assessment.

Leaders did not have the skills, knowledge, and experience to perform their roles. Managers, including the new clinical lead, did not have experience in delivering a medically managed detoxification service. Managers had acted on some issues identified in the suspension notice, but concerns around the safety of clients if the service began to operate remained. Leaders did not have a good understanding of what was required to run the service, which was evidenced, when we had to continually explain to the registered manager what was needed to comply with the suspension notice. Leaders did not have a good understanding of the service they managed. For example, it was only after a discussion around risk assessment and a red, amber, and green rating to identify risk, that an on-call procedure was created.

Leaders had not implemented safe systems and processes to provide safe and good quality care to clients using the service. Information was not available to us during the inspection and requested information from the previous two inspections remained outstanding. Policies, protocols, and documentation did not accurately reflect how care was to be provided or how the service would operate should the suspension be lifted. Managers had not acted on all issues identified in the suspension notice. The information provided did not address the issues related to the service provided by the named GP, including practicing privileges and vetting of that person. Information that staff needed to provide safe and effective care was unclear, incomplete and at times irrelevant. Governance processes did not operate effectively at team level and that performance and risk were not managed well. The following policies, procedures and in-house training were incomplete: Service user pathway admission process, Risk assessment, Support plans, CIWA-Understanding and observation and recording, Client exit process, Client timetable, house rules. Supervision could not be delivered yet as the service was not operating. Managers were unable to provide a supervision policy.

The registered manager was not aware of or understood that the named GP under practicing privileges required a license as defined by the GMC. The named GP had not been vetted under Regulation 18 (schedule 3) fit and proper person employed, to ensure the named GP was a fit and proper person to be employed.

Not all staff had Safeguarding Adults and Children training on how to recognise and report abuse, appropriate for their role. There were still gaps in safeguarding children level two training. For example, only one of the three therapy staff had completed level 2 safeguarding adult’s training and none of the therapy staff had competed level 2 safeguarding children’s training. All the registered nurses had completed safeguarding adults’ level 3 training, but not safeguarding children level 2. Gaps remained in safeguarding adults and children’s’ training on how to recognise and report abuse, appropriate for their role. This issue was specified in the suspension notice that was issued following the first inspection.