Passmores House

Updated 18 March 2019

Passmores House is a residential substance misuse service which can support up to 23 clients requiring a medical detoxification and rehabilitation programme. The provider admits both male and female clients. At the time of the inspection the service had 17 clients.

The service is registered for the following CQC regulated activities:

• Accommodation for persons who require treatment for substance misuse.
• Treatment of disease, disorder, or injury.

The Service has a registered manager.

We last inspected this service on 19 April 2018. Following this inspection, we found the following areas the provider needed to improve.

• The provider should ensure that they document mental capacity assessments when they feel the client lacks capacity.
• The provider should ensure that the ligature risk assessment identifies all ligature points and includes an action plan as to how they will mitigate identified risks.
• The provider should ensure that staff complete an individualised risk assessment for clients in mixed sex accommodation.

Updated 18 March 2019

We rated Passmores House as good because:

• The ward environment was safe, clean, well equipped, well furnished, well maintained and fit for purpose. The service had appropriate arrangements in place for managing medicines and controlled drugs. The service had enough nursing and medical staff, who knew the clients and thoroughly assessed their risks throughout their admission. Staff reported incidents in line with the providers policy and knew how to protect clients from abuse, by working with various organisations. All staff received an induction, regular supervision and could access specialist training.
• Staff, including an on-site GP assessed the physical and mental health of all clients on admission, created care plans and kept them updated during admission. Clients said this was supportive to their treatment. The doctor wrote a discharge summary for each client when they completed detoxification and when they completed rehabilitation to ensure continuity of treatment. Staff managed the waiting list and potential clients could be prioritised if their risk was high.
• Staff followed National Institute of Health and Care Excellence and Department of Health guidance for treatment by encouraging their clients to live healthier lives and offering a range of supportive therapies to aid recovery.
• Staff treated clients and family members with compassion and kindness, and supported clients to make decisions on their care for themselves. Staff used assessment tools which considered all principles of the Mental Capacity Act. Staff supported clients to access services in the local community such as legal advice and housing support. The service had received many compliments and treated concerns and complaints seriously, investigated them and learned lessons from the results.
• Staff allocated bedrooms based on a holistic assessment of the client’s physical health needs, vulnerabilities and gender. The service offered a range of food choices to meet people’s needs.
• Staff felt respected and were aware of organisational vision and strategy. Managers and staff monitored the performance of the service and participated in national benchmarking projects. Senior managers engaged with staff, clients, and family members on how to improve the service.

Updated 22 June 2018

See overall summary.