On 29 November 2017, CQC published ‘Substance misuse services: The quality and safety of residential detoxification’, a briefing of the 2016/ 2017 inspection cycle.
The document, which is necessary reading for all within the sector, is significant for its almost exclusively negative tone.
The 9 page document contains no reference to the hard work of frontline staff; no recognition of providers choosing to work with some of the most vulnerable in society; no thanks for the great benefits that these services provide to individuals and to society generally.
From the 68 services analysed, CQC identified a number of general concerns, including:
- Providers that did not assess risk to individual clients adequately.
- Services that did not follow best practice guidance.
- Poor management of medicines, including controlled drugs.
- Providers that did not provide staff with relevant training.
- Failure to safeguard clients by carrying out employment checks on staff.
Certain concerns raised within the document are those that you would likely find in an overview of any segment of the healthcare sector. For example, record keeping errors were found to be common, referring to the familiar adage that ‘in healthcare, if it is not documented, it didn’t happen’.
Other concerns are, in my experience, far more likely to be found in the substance misuse services. For example, the reference to failing to provide treatment in line with the NICE guidelines. Whilst we cannot be certain of the specific facts, I have seen this criticism raised incorrectly in a number of substance misuse service inspection reports. NICE guidelines are just that: guidelines not tramlines. There are numerous valid reasons why a service may choose to depart from them; decisions which have been taken with care and with direct reference to the specifics of that service’s client group. We have been successful in challenging CQC in their criticisms by demonstrating why the service chose their particular course of treatment or medication. In doing so, we have demonstrated that inspectors often make judgements about substance misuse services based upon a misunderstanding of the client-base and misapplication of guidance from other areas of healthcare.
Likewise, the issue of ‘complex and varied healthcare needs’ is referenced. As providers will be acutely aware, those experiencing long-term drug or alcohol dependence often suffer from a range of health issues, mental and physical; many of which reduce or disappear during detoxification. Providers know this and risk assess the suitability of admission accordingly. Were one to believe this briefing, it would seem that providers regularly admit clients with health needs they cannot meet, knowingly or recklessly indifferent to the potential dangers to the individuals. Despite the number of times I have read this in draft inspection reports, I have yet to find this to be true once the circumstances of the examples are explored.
Indeed, many of the findings highlighted within this briefing could be said to be reflective of a regulator which has entered a new sector and was not prepared for the practices they found. This is reflected in the statistics which make for stark reading:
Of the 68 providers, 49 (72%) were required to make improvements after findings that they had breached regulations of the Health and Social Care Act and failed to meet fundamental standards of care. 43 providers (63%) were found to have breached Regulation 12 (Safe Care and Treatment) and 8 providers (12%) were served with enforcement action.
In summary, this is indeed stark but necessary reading. It provides an insight into CQC’s concerns, allowing providers and staff to reflect on their own practices, address any they find wanting, and ensure that they have the evidence to justify why they have chosen a particular course of treatment or medication.
It is not pleasant or encouraging reading, but it provides the sector with an insight into its regulator’s view of it. Whether you agree or disagree with its findings, it is always better to know; forewarned is forearmed.