Inspection on 12/10/07 for Smithfield Detoxification Unit

This inspection was carried out on 12th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 20 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Smithfield Detoxification Unit 21/04/08

Smithfield Detoxification Unit 05/12/06

Smithfield Detoxification Unit 23/02/06

Smithfield Detoxification Unit 22/09/05

Smithfield Detoxification Unit 10/11/04

Smithfield Detoxification Unit 08/06/04

Similar services:

Littledale Hall Therapeutic Community

Bennett House

Padgate House

Mary & Joseph

Westcliffe House

Richards House

Hamer Cottage

Turning Point (Hoole Road)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Smithfield Detoxification Unit Thompson Street Collyhurst Manchester M4 5FY Lead Inspector Val Bell Unannounced Inspection 12 , 15 and 23 October 2007 10:00 th th rd Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Smithfield Detoxification Unit Address Thompson Street Collyhurst Manchester M4 5FY 0161 839 8829 0161 839 8825 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Turning Point Care Home 32 Category(ies) of Past or present alcohol dependence (0), Past or registration, with number present alcohol dependence over 65 years of of places age (0), Past or present drug dependence (0), Past or present drug dependence over 65 years of age (0) Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users require care/treatment by reason of either past or present drug dependence (maximum 10 places) or past or present alcohol dependence (maximum 22 places) Service users requiring care by reason of past or present drug dependence will be accommodated for a maximum of one month. Service users requiring care by reason of past or present alcohol dependence will be accommodated for a maximum of ten days. 16th August 2007 Date of last inspection Brief Description of the Service: The Smithfield Project is a registered service providing a residential detoxification service with 22 places for people with primary alcohol dependency, and 10 places for people with primary drug dependency. Alcohol detoxification is generally based on a 10-day programme. The drug detoxification service is based on a 28-day programme and some clients are admitted to the drug detoxification unit for a 14-day stabilisation period. The Care Pathway Co-ordinator receives referrals, prioritises need and either offers the client an assessment/admission date, or if there is no bed available, adds the client to a waiting list. The project is situated very close to Manchester City Centre, with easy access to public transport routes. The building also contains administrative offices. Bedroom accommodation is based on the ground floor and the first floor for the alcohol unit and the first floor for the drug unit. All bedrooms are single with hand washbasins. Communal space is provided in both units along with a range of kitchen, dining and laundry facilities and a lift is provided for clients with restricted mobility. Both units are completely separate, although clients can attend all support groups or participate in the therapeutic programme, and share the communal activities room. Registered nurses and support workers are on duty throughout the 24-hour period. The fees charged for the service are £167 per night (contract price) and £205 per night (spot purchase price). Fees are usually paid by the relevant Primary Care Trust or, very occasionally, privately. Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the last inspection on 5 December 2006. Site visits to the home form part of the overall inspection process and two inspectors conducted visits during daytime hours on Friday 12 October and Monday 15 October 2007. The lead inspector conducted a third visit to the home on Tuesday 23 October 2007. The opportunity was taken to look at the core standards of the National Minimum Standards (NMS). This inspection will also be used to decide how often the home needs to be visited to make sure that the required standards are being met. During the visit, time was spent talking to ten people living in the home and discussions were held with the registered person, the locality manager, a person from the organisations risk and assurance department, two support workers, three nurses and three members of the catering department. Satisfaction surveys had been issued to five people that had used the service and one of these was completed and returned to the Commission. Relevant documents, systems and procedures were assessed and a tour of the home was undertaken. The Commission’s pharmacist inspector assessed medication management. The acting manager completed an Annual Quality Assurance Assessment (AQAA) prior to this inspection. This document contained the manager’s views on how well the service was meeting the National Minimum Standards for Younger Adults. What the service does well: What has improved since the last inspection? Nine requirements were made at the last inspection in August 2007 and two of these had been met by the time of this inspection. These related to the need to make a safeguarding referral to Manchester Social Services and the need to notify the Commission of incidents that affected the health, safety and welfare of people using the service. Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 6 What they could do better: Twenty requirements and six good practice recommendations were made during this inspection. Seven of the requirements have been re-iterated from the last inspection report. The requirements highlighted serious concerns that potentially placed people using the service at risk. Although the Statement of Purpose and Service User Guide had recently been reviewed and updated, these documents required more detail to comply with the Care Homes Regulations 2001. The quality of information found in the ten care records examined was poor. Three people accommodated for drug detoxification did not have any care plans in place. The other seven care plans lacked detail to guide staff in what they should do to safely deliver care and support. Risks identified in assessments of need were not adequately assessed or managed and very little attention had been paid to recording the diverse needs of people using the service. Care records were not being reviewed in accordance with the policies and procedures laid down by the organisation. Consequently it could not be determined if these records reflected individuals’ current needs. There was no written evidence that people admitted to the home had been consulted about how they would like their care to be provided and this compromised individuals’ right to make decisions that affected their daily lives. No significant improvements had been made in any aspect of safe medication handling as required at the previous inspection in August 2007. The records relating to medication must be accurate so that all medicines can be accounted for at all times. People who use this service must have their prescribed medicines available for them at all times so that their treatment can be continuous, and all medicines must be administered as prescribed. Safe and legal arrangements for the storage and disposal of medicines must also be made. Nutritional assessments must be undertaken for people admitted to the home to ensure that their diets are suitable in meeting their nutritional needs. Two people spoken to said that they were provided with facilities to prepare their own drinks but not their own snacks. These facilities must be provided. Complaints records were not available for inspection during the three visits to the home, as the acting manager who was off work sick had retained the key to their safekeeping. These records must be available for inspection on request. One person accommodated in the home said that he could not sit on the chairs in the activities room as he suffered from a painful back condition and the chairs provided were too low for his comfort. Furniture must be provided that is suitable to meet the assessed physical needs of people using this service. Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 7 Staff employed by the home had lacked management support and supervision during the three months prior to this inspection. A requirement was made to assess individual staffs’ training, development and supervision needs and to submit an action plan to the Commission detailing how these needs would be met. There was no evidence that a system was in place to monitor or audit the quality of the service provided. A quality review must be undertaken and the findings must be written down and made available to the Commission and people who use the service. In order to track the improvements that are required the registered person must also ensure that monthly reports on the conduct of the service are submitted to the Commission. The five good practice recommendations were made to address minor shortfalls in meeting National Minimum Standards. These related to the provision of a person-centred approach to care planning, referrals to mental health services for people suffering mental ill health, improvements in the content of daily records and recruitment information and a sustained improvement in the way staff interact with people using the service. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Failure to assess, monitor and provide treatment and support for people suffering mental ill health and/or physical disabilities, potentially places their health, safety and welfare at risk. EVIDENCE: On receipt of a referral to this service, the Care Pathway Co-ordinator liaises with the relevant health and social care personnel involved in the person’s care to gather as much information as possible in relation to the support that an individual will need following admission. Admissions are planned according to individual need and circumstances. On admission people are assessed by the triage nurse who records their personal details and needs in relation to substance misuse, past and present physical and mental health, relationships and other relevant information. This assessment process also identifies potential risks to individuals’ safety and welfare during the treatment programme. Care records belonging to ten people were examined during three site visits to this home. The ten assessments of need detailed relevant information needed to undertake detoxification treatment programmes. There was little evidence that the assessment process identified needs in relation to diversity issues, such as disability, religious persuasion or the cultural Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 10 background of people using this service. One person living in the home had a chronic back condition. His assessment did not identify that he needed support to access the first floor by using the lift. He told the inspector that using the stairs ‘jarred’ his back causing him much discomfort. He added that service users were not allowed to use the lift without being accompanied by staff. In addition to a history of substance misuse, seven of the ten assessments recorded that the individual suffered from and was receiving treatment for some form of mental ill health (dual diagnosis). Current good practice guidelines issued by the Department of health state that specialist substance misuse services should work closely with mental health services to ensure that care is well co-ordinated as people with a ‘dual diagnosis’ are at higher risk of relapse, readmission to hospital and suicide. The care records, for the seven people referred to above contained no evidence that contact had been made with mental health services. Furthermore, one of the seven people mentioned above told the inspector that he had moved into the home three days previously and had not been administered medication that his doctor had prescribed for anxiety. These shortfalls potentially placed these two individuals’ health, safety and welfare at risk. The home’s Statement of Purpose and Service User Guide had recently been reviewed and copies of the updated documents were provided on request. Both documents were in need of further review and updating to include the following information. The Statement of Purpose did not contain an organisational chart to inform people using the service of the names and individual responsibilities of staff and management or details of the qualifications and experience of the registered person and staff working in the home. Furthermore, this document should detail the arrangements that are available to support people in attending religious services of their choice. The Service User Guide did not specify that people using the service have the right to access a copy of the home’s most recent inspection report. Wording in this document in relation to the provision of personal care was ambiguous. This should be updated to specify the type of personal care that can be provided to people using the service. These amendments are necessary to assist people in making decisions about whether their assessed needs can be met. Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Shortfalls in care planning, and risk management systems has placed the health, safety and welfare of people using the service at serious risk. EVIDENCE: Care records for ten people were examined during three site visits to the home. It was of serious concern that four people out of five admitted to the drug detoxification unit had no care plans in place. Risk assessments for two of these people identified that they suffered from enduring mental ill health. In the absence of care plans there were no instructions written down for staff to monitor mental wellbeing and there was no mention in daily records that regular monitoring was being undertaken. Five care records examined on the alcohol detoxification unit did contain care plans although these were found to contain insufficient information for ensuring that people received safe and appropriate care according to their Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 12 assessed needs. For example, one of the care plans did not detail that the person’s mental wellbeing needed to be monitored, no risk assessment had been undertaken to safely manage the person’s epileptic seizures and there was no risk management plan in another person’s records in relation to identified allergies, suicide or self-harm. This failure to adequately assess and manage risk was of particular concern following a recent incident where a person was discharged with his medication, despite information shared at the referral stage that this person had a history of self-harm through overdosing on medication. The individual concerned subsequently took an overdose and was admitted to hospital. Although the inspector was assured, by management that discharge procedures had been reviewed, it was evident that no such review had taken place with care plans to ensure that vital information was being recorded. This failure to clearly highlight and manage serious risks through the care planning process places the welfare, health and safety of people using the service at serious risk. People admitted to the alcohol detoxification unit are initially accommodated on the ground floor to aid close observation in the early stages of withdrawal. The inspector was told that people are not moved upstairs until the outcome of a review states it is safe for them to do so. However, there was no evidence in the five care plans that these reviews had been written down. Care plans contained no written information relating to enabling people to make decisions with respect to how they would like their care and support to be provided. For example the person referred to in the sections entitled ‘Choice of Home’ and ‘Lifestyle’ had specific needs relating to a physical disability and his preferred eating habits. His care plan had not addressed these needs and his views, choices and preferences had not been taken into consideration. This person confirmed that he had not been given the opportunity to say how he would like these needs to be met. Turning Point, the organisation, developed a strategy for ensuring a person-centred approach during 2005 – 06 with a target date for implementing this approach in all services from September 2006. It was disappointing that the target date had not been met for the Smithfield service although management gave an assurance that implementation was planned for the near future. Consequently, care plans lacked evidence of consultation in relation to decision-making with people using the service. As an interim measure, care records should include evidence of engagement with individuals’, to agree their personal goals, aspirations and preferences relating to how their support needs will be met. Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Failure to assess nutritional needs and to ensure that people admitted to the home receive adequate diets potentially places their health and welfare at risk. EVIDENCE: Due to the nature of detoxification programmes the standard relating to supporting people to maintain education and occupation activities is not relevant. Neither is it relevant or within the remit of the Smithfield service to provide support for integration into local community life. However, care records provided evidence that advice and information is available as needed and referrals are made to relevant health and social care services prior to discharge. People using the service are encouraged to maintain links with their family and friends during their stay at Smithfield. Visiting times as stated in the ‘Residents’ Handbook’ are designed to fit in with the treatment programmes Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 14 provided, although visiting outside these times will be considered under certain circumstances. Eight people confirmed that their visitors are encouraged and made welcome by staff. The nature of this service requires that daily routines be structured around treatment programmes and group therapy in the mornings. The lead inspector joined six people in the activities room on the afternoon of the third inspection visit. Four people were playing pool and two were engaged in conversation. One of these said he had been doing a jigsaw and felt this activity was good for his concentration. A second person said that they had free time in the afternoons to engage in socialising with other people living in the home and activities such as playing pool and board games. He added, ‘I get bored sometimes, but I look forward to my mum visiting just before tea-time.’ The six people confirmed that they had been provided with keys to their bedrooms and that staff did not enter their private space without their permission. On the first day of inspection it was noticed on two occasions, that groups of three staff were engaged in conversation amongst themselves, leaving people admitted to the alcohol unit to their own devices. A senior member of the management team confirmed that staff were expected to interact with people living on the unit and not exclusively with each other. The senior manager addressed this with the staff concerned and it was encouraging that staff were observed to interact more with people during the remainder of the inspection. Eight people spoken to praised the quality of the food provided and said that they were offered choices at mealtimes. They confirmed that facilities are provided to make their own drinks but no facilities are provided to prepare snacks between meals. One person said that his mother brought food in for him when she visited. He also said, ‘Mum also brings sandwiches in for (S) because he cannot eat the food here.’ A conversation with (S) revealed that he felt uncomfortable eating in a communal setting and had been refused a request to eat meals in his bedroom. This had been identified during the assessment process, but had not been included in his care plan. It was very worrying that staff had not picked up on the fact that (S) had not eaten any meals since his admission the previous week. His daily notes stated, ‘Diet and fluids taken well.’ Although the inspector brought this to the attention of nursing and support staff on the alcohol unit, they did not express any concern for this man’s welfare. These issues were passed on to the home’s management team to be investigated. Due to the potential for eating disorders associated with alcohol and drug dependency, it is required that nutritional assessments are undertaken with people at the point of their admission to Smithfield. Conversations were held with two chefs and a kitchen assistant in the ‘Café’. The inspector was told that special diets, such as diabetic and Halal meals were available and it was evident that kitchen staff had a good understanding of the cultural and ethnic needs of people admitted to the home. Health and safety records required for the safe handling of food were up to date. Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Systems in place for the receipt, storage, administration, recording and disposal of medication are poor and potentially place the health, safety and welfare of people using this service at serious risk. EVIDENCE: People admitted to the home generally require minimal assistance with their intimate care needs. People using the service confirmed that personal support and nursing care was provided in private in a dignified way and that they received encouragement and support to maintain their independence with activities of daily living. The environment was adapted to provide access for people with impaired mobility, although equipment for people with more complex physical needs, such as hoists, was not currently available. Several of the specifications of the standard relating to healthcare are not relevant to this service, which provides only short-term accommodation for the purpose of alcohol or drug detoxification programmes. However, recent Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 16 notifications submitted to the Commission has provided evidence that referrals have been made to National Health Service facilities where necessary. The pharmacist inspector spent two days in the home looking at how medication was handled on both the drug and alcohol detoxification units. The visits were undertaken to make sure that the requirements made at the last inspection had been met and that people were being given their medicines properly. At the last inspection there were concerns because there was not a complete set of policies and procedures available for inspection. The company policies had been reviewed and were available at this inspection. However they did not fully cover all aspects of safe medication handling. For example, the policy failed to give guidance on the safe disposal of all types of unwanted medicines. There were serious concerns that unwanted medicines, including controlled drugs, were not being disposed of in line with Waste Management Regulations applying to nursing homes. This was highlighted at the previous inspection and on the first day of this inspection it was noted that medication had not been disposed of legally. On the second day of the inspection the acting manger said that a contract with a licensed waste management contractor was being arranged in order to make sure that regulations and current legislation were complied with. It was of serious concern that even when the policy provided robust guidance, nurses failed to follow that guidance. For example the policy states that any potentially illicit/illegal substances found in the home should be handed into the police station. During the inspection an envelope containing some brown resin type substance and a paper towel holding a green leafy substance was found in one of the drug cupboards. These substances were stored side by side with peoples currently prescribed medicines. There were no records available to show when these substances had been found or to indicate what attempts had been made to dispose of them. An immediate requirement notice was issued when these substances were found to ensure that they were disposed of legally as soon as possible and to make sure people were not at risk. At the previous inspection it was noted that the records were poor. They did not show how medicines could be tracked or provide evidence that people had been given their medicines properly. During this inspection it was seen that nurses failed to accurately record how much medication arrives and leaves the home and they did not always accurately record what medication each person had been given. The poor records make it difficult to show that medicines are managed properly and whether people are always given the correct doses. The records could not always be relied on to give accurate information. For example one person’s medication administration record sheet (MARs) showed that he had not been given medicines at lunch time or tea time on a particular day because he was away from the unit, although his care notes said that he Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 17 spent the afternoon and evening socialising on the unit. It was difficult to tell which of the records were accurate. It was also seen that a lot of people refused their medication yet records did not show why medicines had been refused or if the doctor had been consulted as to what actions staff should take to ensure the individual’s health was not at risk. It was also of concern that staff could not reliably identify people prior to giving them their medicines, as photographs of individuals were not held on file. Although people who use this service are given hospital style wristbands to wear, staff said it would be easy to swap wristbands. People are at risk of being given the wrong medicines if staff are unable to reliably identify them. At the end of the inspection an immediate requirement notice was issued to ensure that accurate records were kept to provide evidence that people were not at risk from poor medicines handling. During the visit it was of significant concern that people who use this service were not being given their medicines properly. Numerous examples were found where staff had not made proper arrangements for their medicines to be prescribed and supplied. The staff in charge of the home during the visit told the inspector that they were allowed to withhold medication until the doctor had assessed the resident. The inspectors talked to the doctor who said he was very concerned about people not being able to have vital medication when they came into the home and said he ‘was furious’ when he found out one resident did not have any heart medication for four days. An immediate requirement notice was issued at the end of the inspection to make sure that medicines were obtained to enable continuous treatment. The notice also required the nurses to administer medicines exactly as they were prescribed so that individuals’ health was not put at risk. The storage of medicines awaiting collection for destruction was of concern. Some unwanted medicines were in a drawer in the same cabinet as current medicines. Tablets, which had been ‘dropped’, were put in a tablet bottle together and there were no accurate records to show who they had belonged to or how many had been ‘dropped’. Controlled drugs, which were no longer needed because the people had left the home, were kept in the drug cabinet alongside the drugs prescribed for people who were currently living there. Medicines, which are no longer needed, should be stored securely away from currently prescribed medicines to avoid any errors being made. The records associated with medication, which was no longer needed, were poor and did not make sure that these medicines could be accounted for. The handling of controlled drugs was a serious concern. The management of the service did not think that the controlled drug cabinets met current standards and legislation. This was a cause for concern. The records regarding controlled drugs showed that some of them could not be accounted for. There were a number of discrepancies, which had not been reported or noticed by the management. There were also significant discrepancies in the quantities of stock medicines. When the records regarding chlordiazepoxide Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 18 were examined together with the actual stock it was found that some of the capsules were unaccounted for. When medication is missing or cannot be accounted for the health of people who use this service may be at potential risk. Because of this concern an immediate requirement notice to investigate the discrepancies was made. The staff who administer medicines are qualified nurses. These nurses have demonstrated a serious lack of competence, which could put the health of the people who use this service at significant risk. It is essential that nurses have refresher medication training and are assessed as competent in all aspects of medicines handling to safeguard the health of people who use this service. The requirements made during the previous inspection visit had not been met and the health of people living in this home was potentially at significant risk from poor medication administration. Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People knew how to make a complaint but how they were dealt with was not known. EVIDENCE: The ‘Resident’s Handbook’ clearly outlines the procedure people should take if they wish to express concerns or make a complaint about the quality of the service they receive. This includes the timescales for responding to and resolving complaints. Ten people and one person completing a satisfaction survey confirmed that they knew who to speak to if they had concerns or complaints. The complaints log was not available for inspection during the lead inspector’s three visits to the home. The locality manager explained that the key for the complaints log’s safekeeping was held by the acting manager who was currently absent through sickness. Details of action taken in response to complaints received by Smithfield must be available on request for inspection by officers of the Commission. During the inspection an anonymous caller to the Commission expressed concerns about the management of the service and also stated that window openings on the first floor of the building were not being restricted to prevent people falling out. These windows were examined and all were found to be suitably restricted as required. The findings relating to how the home is being managed are detailed under the section entitled ‘Conduct and Management of the Home.’ Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 20 At the previous inspection in August 2007, the inspector was informed of a serious incident where a previous service user had been discharged with his medication, despite a risk assessment stating that this person had a history of overdosing. Following discharge the service user had taken an overdose and the service user’s mental health support worker made a complaint to the home. Since then the incident had been reported to the local authority for investigation under the safeguarding adults from abuse procedures. The outcome of the investigation had resulted in disciplinary action and suspension of two members of staff. The inspector was given an assurance that discharge procedures had been reviewed to ensure that good practice guidelines would be followed in protecting the welfare of people discharged from the home. Further work is needed to ensure that staff have up to date information in care plans to enable the safe discharge of people using this service. This is detailed in the section entitled ‘Individual Needs and Choices.’ Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment was clean and hygienic, however failure to provide appropriate furniture to meet the assessed physical needs of people using the service, places their health and welfare at risk. EVIDENCE: A tour of internal and external areas of the home was undertaken, including communal and private space. Some redecoration had been undertaken in the previous twelve months and the environment was found to be clean and hygienic, with no unpleasant odours present. The planned refurbishment mentioned in previous reports had not started, due in part to failed negotiations concerning an application for funding from the home’s landlord, The Guinness Trust. A person living in the home at the time of this inspection said that he suffered from a chronic back condition and wore a surgical corset. He remarked that the chairs in the activities room were too low for him to sit in. No alternative Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 22 seating arrangements were available so for his own comfort this man had to stand during the time he spent socialising in this room. Patio doors from the activity room led into an attractive garden and patio area, with seating and a shelter that had been designated as a smoking area. Records provided evidence that servicing and maintenance of the home’s electrical and gas equipment was up to date. Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Failure on the part of staff to follow good practice guidelines potentially places the health, safety and welfare of people using the service at serious risk. EVIDENCE: Written information provided prior to the inspection visits detailed planned improvements in staff development for the next twelve months and the recruitment of new team leaders for the drug and alcohol detoxification units. Planned training included clinical training for nurses and support staff and training in specialist areas such as cognitive behaviour therapy. Observations and examination of records during the three visits to this service provided evidence that nursing and support staff lacked guidance and leadership in adhering to the organisation’s policies, procedures and protocols. The potentially serious consequences of this have been reflected in the findings of this report. This was also recognised by the acting manager who wrote, ‘We need to ensure tighter supervision and support for all staff; and to recruit team leaders who will role model and enable a more consistent professional delivery.’ The current situation has resulted in a potential for the health, safety and welfare of people using the service to be at risk. It is required that Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 24 each individual member of staff receives regular one-to-one supervision and an assessment of their training and development needs, which must include refresher training in medicines management. An action plan must be submitted to the Commission detailing how and in what timeframe their supervision and development needs will be met. Recruitment records for this service are held centrally at the organisation’s head office in Manchester and a person appointed by the Commission inspects these on an annual basis. The records were found to be in good order at the last inspection and were due to be inspected again during November 2007. The inspector was informed that Smithfield unit should have had a record in place, which lists the date of Criminal Record Bureau disclosures, Protection of Vulnerable Adults (POVA) list checks and references. However, this was not provided during this current inspection. Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 and 43 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Shortfalls in the way the home has been managed and the absence of an effective quality monitoring system have potentially placed people using this service at serious risk. EVIDENCE: The staff team had undergone significant changes at senior level during the three-month period prior to this inspection. This was due to a restructuring process aimed at resolving issues relating to the need for staff to develop a better understanding of what is expected from them in terms of their approach in meeting the needs of people using the service. From conversations with nursing and support staff it was evident that this had affected team morale, although individual staff also commented that they were confident that the Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 26 proposed changes in management would result in a more supportive working environment. The registered manager and one of the team leaders were currently suspended pending disciplinary investigations and the second team manager had been dismissed. An acting manager had been appointed as an interim measure, although this person was currently absent due to sickness. The service was currently receiving direct management support from a locality manager, the responsible individual, a person from the organisation’s risk and assurance department and a senior nurse. Recruitment was underway to employ a more established management team. As detailed throughout this report, significant pieces of work must be undertaken by the current managers to ensure that people using this service have their assessed needs met safely. In relation to quality assurance the acting manager provided the following written information to the Commission, ‘We have improved our monitoring procedures; we have introduced a new organisation-wide computer informations client management tool (CAREPATH), which has been implemented successfully in this service.’ It was not clear what information this system was designed to monitor although it clearly had not captured vital information relating to the shortfalls found during this inspection. Neither was there any evidence that continuous self-monitoring or internal auditing had taken place. It is required that a system is established to regularly review and improve the quality of the service provided. This is to ensure that people referred to the home receive a safe, consistent and reliable service that meets their individual needs in a person-centred way. A copy of the review must be submitted to the Commission and made available to people using the service. Additionally, the organisation must appoint a person to visit the home every month and to prepare written reports detailing the conduct of the home, as required by Regulation 26 of the Care Homes Regulations 2001. These reports must be submitted to the Commission on a regular basis. A sample of health and safety records was examined and found to be accurate and up to date. The home received a fire safety inspection during August 2007. The fire officer found fire safety systems to be satisfactory and no health and safety issues were found during this inspection. Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 1 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 X 34 3 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 N/A 14 X 15 3 16 2 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 1 X 1 X X 3 1 Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 28 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 (2) Requirement Immediate Requirement Notice stated • Ensure that all clients have an adequate supply of medication to ensure continuity of treatment. • Ensure that all medicines are given as directed by the prescriber. • Ensure that all records are accurate With immediate effect. Immediate Requirement Notice stated • To appropriately dispose of illicit substances within 24 hours. To ensure all medication can be tracked by means of an auditable trail within 24 hours. Timescale for action 15/10/07 2. YA20 13 (2) 16/10/07 3. YA20 13 (2) Immediate Requirement Notice 17/10/07 stated You must investigate the discrepancies in medication stock and investigate the potential losses and report those findings by fax within 48 hours. Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 29 4. YA2 13 (1) (a) Arrangements must be made, where necessary, for service users to receive treatment, advice and other services, such as assessment of their mental and physical health needs. People admitted to the home must have a care plan that details how their health and welfare needs will be met. Care plans must be subject to regular review. People admitted to the home must be enabled to make decisions on how they would like their care and support to be provided. Risks to the safe delivery of care and support must be assessed and clear written guidelines provided to inform staff what they must do to keep people safe. Facilities must be provided for people using the service to prepare their own snacks and to eat their food in private if they so wish. Nutritional assessments must be undertaken for people admitted to ensure that they are provided with suitable diets that meet their assessed needs. The medication policies and procedures must cover all aspects of medication handling, in order to give staff guidance so that people’s health is not placed at risk. 23/11/07 5. YA6 15 23/11/07 6. YA7 12 (2) 23/11/07 7. YA9 13 (4) (b) & (c) 23/11/07 8. YA17 16 (h) 23/11/07 9. YA17 12 (1) 23/11/07 10. YA20 13 (2) 30/10/07 Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 30 11. YA20 13 (2) Any suspected illicit substances brought into the home must be dealt with in strict accordance with the homes medication policy, in order to ensure that health of people who live at this service is not placed at risk from harm. These arrangements must be made to ensure that health of people who live at this service is not placed at risk from harm. 22/10/07 12. YA20 13 (2) All medication records must be 15/10/07 accurate and up to date and all medication must be accounted for by means of an auditable trail to show that people are administered their medicines as prescribed. All medication must be administered to people in exact accordance with the prescribed directions to make sure their health is not placed at risk. All medicines must be stored securely in accordance with current legislation to ensure that people are not at risk. All nurses who handle and administer medicines must be trained and assessed as competent to do so safely, to ensure that people are given their medicines safely. A summary of complaints made in the previous twelve months and the action taken to resolve them must be submitted to the Commission. Suitable furniture that meets the assessed physical needs of people using the service must be provided. 15/10/07 13. YA20 13 (2) 14. YA20 13 (2) 30/11/07 15. YA20 18 (1) 30/10/07 16. YA22 22 23/11/07 17. YA24 23 (2) (g) & (h) 23/12/07 Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 31 18. YA35 18 (1) (c) & 18 (2) An action plan detailing supervision arrangements and the training and development needs of staff must be submitted to the Commission. The quality of the service must be reviewed and a report on the findings must be submitted to the Commission and made available to people using the service. A senior person in the organisation must visit the service monthly and prepare a report on the conduct of the service. Copies of the reports must be submitted regularly to the Commission. 23/12/07 19. YA39 24 23/12/07 20. YA43 26 23/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations The Statement of Purpose and Service User Guide must be reviewed and updated to ensure that people using the service have accurate information to assist them in deciding if the home can meet their assessed needs. Referrals should be made to mental health services for people who experience mental ill health. This is to ensure that the best advice is available in ensuring their care is well co-ordinated. Daily records should include details of the outcome of monitoring individuals’ physical and mental health needs. A person-centred approach to care planning should be implemented. This will provide evidence that the personal goals, aspirations and preferences of people using the DS0000021657.V349984.R01.S.doc Version 5.2 Page 32 2. YA2 3. 4. YA6 YA7 Smithfield Detoxification Unit service are respected and met. 5. 6. YA16 YA34 Staff should be encouraged to talk to and interact with people using the service, not exclusively with each other. A record detailing the date of CRB disclosures, POVA list checks and references should be made available for inspection. Smithfield Detoxification Unit DS0000021657.V349984.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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