Three locations, all run by the same provider – PROMIS Clinics – in Kendrick Mews in the London borough of Kensington and Chelsea, have been rated Inadequate by the Care Quality Commission.
All have been placed into special measures following inspections in May 2019. No 11 Kendrick Mews is a three-bedded unit based in a mews house. It is run by PROMIS clinics, which has two other services on the same street at No 12 and No 4.
While the three are registered separately, they operate as one service with the same manager and the same staff covering the three locations. CQC completed the inspection which reviewed the three registered locations.
Clients in the three services use the same communal areas in No 11, including a kitchen and a living room. The clinic room for the three services is in No 11. There are some therapy rooms in No 12, which are used by clients across the services. The premises were not being properly protected from the risk of fire.
The service provides medically monitored alcohol and drug rehabilitation services including a psychological therapy programme. CQC inspectors were concerned that the provider had not full taken account of a CQC briefing (supported by Public Health England) on the quality and safety of detoxification in residential substance misuse services. This was circulated to providers of all relevant services in 2017.
The service did not provide safe care for clients undergoing alcohol detoxification. The provider accepted clients for alcohol detoxification who had a history of alcohol withdrawal seizures and delirium tremens. This carried a level of medical risk that was not fully assessed prior to admission.
Clients did not have a comprehensive assessment before commencing alcohol detoxification treatment. There was no record that clients had a physical examination, including for clients with a reported physical health problem. This included clients with possible or actual liver disease.
Clients’ medical and mental health history was not always obtained from other healthcare professionals prior to detoxification treatment.
One of the GPs prescribing for clients undergoing alcohol detoxification treatment had not had any specific training in treatment for substance misuse.
However, at CQC’s last inspection, inspectors identified that physical health monitoring equipment had not been regularly serviced and staff were not aware of their duty of candour. At this inspection, these matters had been resolved.
People were cared for in a clean and comfortable environment and there were enough staff to meet the needs of the client group. Clients were supported and treated with dignity and respect and were involved as partners in their care. Clients were supported to understand and manage their care and treatment. The service offered family interventions and post discharge support groups.
At number 4 Kendrick Mews there were no clients in residence, but inspectors rated both safe and well-led categories as Inadequate. CQC could not gather sufficient evidence to answer the remaining key category questions.
Dr Paul Lelliott, Deputy Chief Inspector (and lead for mental health) said: “We have placed all three PROMIS Clinics in Kendrick Mews into special measures.
“I am placing the three services into special measures due to their failure to follow best practice for the safe detoxification of clients withdrawing from alcohol, their failure to protect their premises from the risk of fire and the lack of management oversight of safety and quality.
“The service will be kept under review and, if needed, we will take further enforcement action. We will conduct another inspection within six months, and if there is not enough improvement we will move to close the service.”
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