Archived: The John Kitchen Centre

This was an unannounced, comprehensive inspection. We rated The John Kitchen Centre as inadequate. Immediately following our inspection, we took enforcement action to stop the provider from accepting new clients for detoxification treatment with immediate effect. We are also taking enforcement action where we will be proposing the cancellation of the registration of this location for the provider. This would mean that the provider will no longer be able to operate this service.

Overall, we rated the service as inadequate because:

• CQC previously inspected The John Kitchen Centre in August 2016. Following the August 2016 inspection, we told the provider that it must act to improve the service. During this inspection we found that the actions needed to improve the service had not been taken. This included improving the safety of medication management, ensuring that appropriately detailed records relating to risk management and the delivery of care were maintained for each client, that the necessary pre-employment checks were completed for all staff and that an appropriate governance structure and auditing system was put in place.

• Staff did not manage the care of people undergoing detoxification safely. The service did not identify and exclude clients whose needs could not safely be met by the service. Staff did not complete a comprehensive assessment of clients’ needs, including their needs for physical healthcare or the extent and nature of their drug or alcohol dependence, before clients commenced detoxification treatment.

• Staff did not undertake ongoing monitoring of clients’ withdrawal symptoms and physical healthcare status as required by the provider’s detoxification protocols. This posed a risk that a physical deterioration in clients undergoing detoxification treatment would go undetected.

• The service did not have appropriate arrangements in place to respond to emergencies or access medical advice out-of-hours.

• Staff did not provide clients with sufficient information about treatment options, or the risks associated with their treatment, nor did they document their consent to treatment. Staff did not alert clients to the risks they faced if they exited treatment early. For example, the risk of loss of opioid tolerance - leading to risk of overdose - and the risk of seizures.

• Staff did not assess the risks to individual clients adequately on admission nor did they put plans  in place to safely manage these risks. The service did not assess clients’ mental health to determine whether their drug or alcohol misuse was masking an underlying condition.

• The provider did not have governance processes in place to provide assurance about the quality and safety of the service, and to alert the provider to improvements that needed to be made. Managers did not audit the management of medicines, the quality and completeness of clinical records or staff employment files. Staff did not manage medications safely. They did not ensure that medications were stored safely, they did not undertake risk assessment of clients who administered their own medication and the provider had no system to enable staff to check if medications were missing. Staff did not manage risk posed by potential ligature anchor points to protect clients who were vulnerable to suicide or self-harm. The service did not consider the gender mix or location of clients’ bedrooms, meaning that the provider was not doing all that was practicable to mitigate the risk of sexual safety incidents occurring.

• The provider did not complete the necessary pre-employment checks to provide assurance that volunteers and staff were suitable to work at the service.

• Staff did not work within their qualification or competency level and the provider did not assure itself that staff and volunteers were competent to carry aspects of their roles including managing medications.

• The service had not developed a culture of learning from incidents. Incidents were not discussed routinely by staff and staff did not act to identify learning from incidents to make improvements to the service.

• The provider did not have sufficient information available to staff about how to make a safeguarding referral.

• There was no system to ensure the provider’s policies and procedures were regularly reviewed and reflected up-to-date professional guidance. Policies were not dated.