Liberty House Clinic Limited

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We rated safe as requires improvement. We found one breach in regulation 12, safe care and treatment. We assessed 7 quality statements. Medicines were not reviewed regularly and there were frequent incidents relating to medicines. Staff did not always demonstrate that they knew how to recognise adults and children at risk of or suffering harm. The environment did not meet people's needs as there was not enough communal seating for all people and some appliances did not work. Learning from incidents was not robust as there were recurrent incidents of the same nature. However, the environment was clean, staff had robust recruitment processes with up-to-date mandatory training and there was a good incident reporting culture at the service.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they were aware of the complaints process, which was detailed in their admission documents. They found community meetings beneficial for addressing some of their concerns. We spoke to people who used the service and carers as part of our assessment and monitoring process who had experience of raising concerns with the service. Some people told us they did not always feel confident to raise concerns or that concerns would be addressed fairly.

Staff raised concerns and reported incidents, serious incidents and near misses in line with policy. We reviewed the service’s incident log to confirm this. There was a good reporting culture among staff. Incident investigations confirmed that staff were debriefed and offered support after a serious incident. Leaders investigated incidents where appropriate. Reports were thorough and addressed all points raised. However, despite an established reporting process, we found a lack of genuine learning and improvement to prevent future incidents. For example, medicines incidents continued to take place. Leaders were seen to be supportive but occasionally defensive when managing incidents and complaints. We saw this documented in staff records, in meeting minutes and it was reflected in the way staff were managed following mistakes. There appeared to be a reluctance by the service to acknowledge there could have been shortfalls in the service people received.

The service had up to date incident reporting processes for internal incidents. We reviewed evidence before and after our assessment that demonstrated the service understood its responsibility to submit statutory notifications. Governance processes showed leaders had oversight of incidents and promoted a positive reporting culture however we saw action to manage risks was not always effective. We reviewed the incident log from January 2023 to December 2023. There were 105 incidents reported in this period. Of those 105 incidents, 20 related to physical health, there were 28 visits to the local emergency department. There were 13 emergency department visits where people had seizures. Despite the efforts to manage and mitigate risks, the number of incidents resulting in hospital attendance raised concerns about the effectiveness of these measures.

People were pre-assessed by a central administrative team for suitability prior to their virtual medical assessment. There were three doctors who worked for the service. A doctor assessed people via a video call before they were admitted to the service. People told us they preferred in-person doctor visits over virtual assessments for more personalised care and clearer communication. Discharge plans were made shortly before discharge, and we were concerned over the adequacy of support to prevent people from relapsing. The discharge process should be part of someone's treatment plan and should be planned as early as possible. Care planning should be timely to maintain people’s health, safety and welfare. One person told us they were concerned that they did not have a discharge plan and they were due to be discharged in the following days.

Staff carried out assessments for each person's mental health at admission, often using self-reported information. Some people provided additional details from GPs or other professionals. The admitting doctor evaluated and approved people's suitability for the service. The doctors we spoke with told us that the support staff were good at escalating concerns and asking for medical support when needed. We saw evidence that staff escalated physical health concerns. We spoke with the 3 doctors who worked for the service. They informed us they did not get involved with discharge planning unless there were complex issues involved. They did not tend to prescribe medication to people upon discharge, instead they preferred to signpost clients to their GP if they had medicine requirements. This practice was not in line with the service’s medication policy, which stated people who used opiates would be prescribed naloxone upon discharge to support them. Naloxone is a medicine that is used to reverse or reduce the effects of opioid use. Staff told us discharge plans were created the day before discharge. We were not assured that this time frame provided sufficient support to ensure discharges were successful and to support people against relapse.

We looked at people's records and saw that people were reviewed and referred by the provider’s admissions team. People signed their agreement to the service’s terms and conditions and the treatment contract. The treatment contract was reviewed at community meetings. Staff carried out weekly audits of care records, which included review of whether the admission process had been completed in line with the service’s policy. Review of the audits showed good compliance with the admissions and discharge policy from August 2023 to January 2024. Staff planned peoples’ discharge and worked with people’s families, where appropriate, to make sure this went well. Each person had a discharge plan, which was completed collaboratively with them, either, on the day or shortly before discharge. At the start of treatment, people knew how long they would be staying, but they could increase their length of stay if they were funding that themselves, or if alternative funding was in place to enable this. People could discharge themselves before treatment had been completed, but staff followed guidance in the service’s policy to support people’s safety if they discharged themselves early. Following completion of their treatment, people were offered an aftercare package that included access to support from therapists and people with lived experience in a weekly online meeting.

Some people told us they generally felt safe at the service and they knew how to raise a concern if they needed to, however some other people told us they were concerned about their safety. For example, one person raised concerns about a male entering into a female's room. Another person raised concerns over mixed-sex accommodation, particularly shared bathrooms. During the assessment, we saw that community meetings took place on a weekly basis. People told us these meetings were useful and that issues they raised were addressed. People signed a contract upon their admission to the service, which outlined how they should behave towards each other.

Despite staff being able to describe how to protect people from harassment and discrimination, including those with protected characteristics under the Equality Act and having completed training in equality and diversity, there were examples where staff did not always demonstrate that they knew how to recognise adults and children at risk of or suffering harm. During the assessment we were made aware of a safeguarding incident that had not been managed in line with the service’s safeguarding policy. Measures had been taken to support the wider client group, but no measures had been put in place to protect the individual concerned. We therefore raised the concern with the local authority following the assessment. However, staff were aware of the service’s safeguarding process and knew who to speak to if they had concerns. At the time of the assessment, the service’s compliance with safeguarding training for adults was 80% and compliance with training for safeguarding children was 90.9%.

The provider’s processes promoted people living in safety, free from abuse, neglect, and avoidable harm. There were systems in place to make sure people were protected from abuse and neglect, however we saw during our assessment that these systems were not always implemented effectively, as we identified a safeguarding concern that we raised with the local authority following our on-site assessment. The service had safeguarding procedures for adults and children, which included the importance of working with other agencies, including the local authority. However, the policies were generic and written at a system level, rather than a local level relevant to a substance misuse service. The safeguarding adults policy contained a lot of information, including the role of the local authority, types of abuse, relevant legislation, however the guidance for staff to follow at local level once they became aware of a safeguarding concern was a small section towards the end of the document. It was not easy and convenient for staff to quickly find the guidance relevant to them. The guidance for staff in the safeguarding children policy similarly appeared to relate more to a local authority organisation and did not have clear guidance for staff. The policies did not make reference to the safe storage of medication in the home after a person's discharge if children were present. One of the senior managers of the company acted as the safeguarding lead. Staff told us they were accessible when they needed to raise a safeguarding concern.

People's care plans were not always person-centred. The quality of the care plans was variable with many being generic. We saw some care records that did not reflect the person's voice. People's risk assessments were completed on admission and we saw that they were updated at various points throughout their admission. People we spoke with as part of the assessment understood the observation framework followed by the service and why it was in place.

Medical staff completed virtual assessments for each person on admission. Staff also completed risk assessments. Support staff were responsible for carrying out basic physical observations on admission. Staff demonstrated an understanding of the management of risk and were aware of the procedures to follow in the event of an emergency or if they needed further support to manage risks to people. Staff followed procedures to minimise risks where they could not easily observe people. The bedrooms were situated over three floors, but there were closed circuit television (CCTV) cameras in all the communal areas, including the meeting rooms. When someone was in their bedroom, staff went to the room to check on their well-being. Staff followed the provider’s policies and procedures when they needed to search people’s belongings or their bedrooms to keep them safe from harm.

Staff completed risk assessments for people upon admission. We reviewed a sample of risk assessments and found that staff asked for consent to obtain a medical summary from people’s GPs before prescribing began. However, this was not always possible, and in the absence of a medical summary, the doctor had to rely on people’s self-report. We had concerns that the provider might admit people that were not suitable for the programme because they required a higher level of physical health monitoring than the service could offer. However, baseline observations were taken for people prior to being admitted, and the doctor could assess people face to face if they deemed this necessary. We saw evidence that the service was monitoring whether observations were being completed appropriately through weekly audits. Leaders did not always provide us with service specific policies. We were given an observation and client well-being check list policy. The policy provided to us referenced a different location and provided direction to support workers to alert the nurse on duty in the event of a medical emergency. There were no clinically trained staff on site to offer triage, quick assistance, and reassurance.

People told us they sometimes felt unsafe due to the mixed-gender accommodation at the service, with both men and women having bedrooms on the same floors and using communal bathrooms. One person expressed disappointment, having been under the impression that there would be separate spaces, including bathrooms. People reported insufficient comfortable seating in communal and dining areas. Feedback highlighted concerns over cramped spaces, a worn-out setting, and old mattresses. Additionally, there were complaints about only one working washing machine for twenty people. People expressed dissatisfaction with a lack of activities at the service during weekends, noting discrepancies between advertised amenities like a gym and ensuite bedrooms, and the reality of only having access to daily short walks. However, during the week, people told us they had access to different activities such as breathwork, quiz nights, bingo nights, yoga and sound therapy.

Staff completed and regularly updated risk assessments of all areas, but they could not always evidence that they had reduced the risks they identified. The service had an independent health and safety assessment carried out in March 2023. The health and safety report concluded the service had high compliance in areas such as accident reporting, first aid and food hygiene, however there were some actions relating to electrical safety and fire documentation. Staff did not demonstrate a good understanding of potential harm to vulnerable people in shared mixed-sex environments, which could increase risks to people. Leaders and doctors told us they did not admit high-risk people. However, we saw evidence in care notes and incident recording that some people had indicators of high risk, such as histories of self-harm, being actively suicidal and there were people experiencing seizures, in some cases in clusters.

We saw that the environment was clean, however it was also dated, worn, and there was a noticeable lack of laundry facilities. The communal areas were not big enough to comfortably accommodate twenty people with enough seating.

The service took steps to manage risk and people’s safety where there was mixed sex accommodation. Most people had their own bedrooms, but there were no separate bedroom corridors for males and females, no female only day spaces, and males and females were required to share bathroom facilities. The service had a risk assessment in place to manage sexual safety and they monitored any sexual safety incidents. Where concerns were identified, we saw staff took action, such as issuing warnings. However, we identified some concerns relevant to sexual safety during our assessment and we found no individual risk assessments or actions were implemented to mitigate the risks.

People told us that staff were mostly kind and amicable. They reported that there were usually enough staff to ensure they received their medicines on time and that staffing levels had improved. However, people told us there were very few activities available to them and that some advertised sessions were cancelled which may have been due to staffing.

During our assessment, we found that many staff members were new to the service, including the registered manager. We observed staff at the service were heavily reliant on one support worker for their knowledge and leadership in operating the service.

There were appropriate staffing levels at the service. Data provided by the service identified that there was a total of 16 staff at the service. Staffing comprised of the manager, administrator, support workers, therapists, kitchen staff, housekeeper and maintenance staff. There were 2 night staff at the service, 1 awake and 1 asleep. There were some vacancies at the service, however the service met staffing requirements. There was 1 support worker vacancy, 1 therapist vacancy with another therapist on long term leave and 1 kitchen staff vacancy at the time of the assessment.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service did not always ensure that medicines and treatments were safe and met people’s needs, capacities, and preferences by enabling them to be involved in planning, including when changes were made. People were involved in initial discussions about their medicines, especially if GP summaries were unavailable to the service.

Staff told us that people brought their medicines in on admission and it was the person's responsibility to contact the GP if they were low on medicines, although staff supported them with this if needed. The GP prescription was then sent to the local pharmacy and staff collected it from there. Clinical monitoring and assessments were conducted by support workers, and then reported to the doctors on duty virtually. Staff told us that they asked people to bring GP summary care records to the service on admission, however we saw that often GP summary care records were not brought in, and staff pre-assessments and medicines reconciliation relied entirely on self reporting and medicines brought in by people. Staff ensured all information was shared with the doctor on duty.

We observed staff administering medicines to clients. Support staff monitored clients for breakthrough withdrawal signs and symptoms, and could use clinical scoring scales as a guide.

Staff were not following controlled drugs (CD) guidelines when they administered CDs to people. We saw that schedule 2 controlled drugs were administered; however, no information was recorded in the CD register to indicate who these were administered to. There was limited evidence that health checks were completed as part of the assessment process, which would be considered best practice. We saw urine drug testing, but in some cases, results were not entered into the client record system. Support staff were responsible for managing and monitoring people who were at risk of seizures. Incident levels were consistently high, with numerous medicines errors and people having seizures. We reviewed the provider's incident log for 2023. There were 104 total incidents recorded. 23 (22%) of these were medicines error incidents. 13.6% of the medicine’s incidents were incorrect dose administration of medicines, and 9.1% of the medicine’s incidents were medicine overdose to clients. From the records reviewed, we did not see evidence of regular review or any additional as required (PRN) medicines protocols for staff to follow. Staff told us that they usually assessed people’s vital signs and uploaded the results for doctors to review. However, cleaning and temperature monitoring were well-documented, with protocols for elevated temperatures. Emergency equipment was checked regularly and patient consent was obtained.