People who are addicted to alcohol or drugs and undergoing medically-supervised withdrawal in residential settings are being put at risk of harm because many independent clinics in England are not providing safe or good quality care, according to a briefing published by the CQC.
The CQC Briefing on Residential Substance Misuse Services is based on inspections over the last two years of the 68 services in the independent sector that have been identified as providing residential detoxification. In it, the regulator has uncovered multiple concerns.
Many of the clinics were found to be not assessing the risks to the safety of the people within their care prior to their admission; were not following recognised national clinical guidance on how to treat people who are withdrawing from alcohol or drugs; were not storing, dispensing and handling medicines appropriately and were not carrying out full employment checks or sufficiently training their staff.
Nearly three in four (72%; 49) of the providers that CQC had inspected were found to have been failing in at least one of the fundamental standards of care that anyone should have a right receive.
The regulation on ‘safe care and treatment’ was where CQC found the most breaches: 43 providers (63%) were not meeting this particular standard at the time of their first inspection.
Examples of what CQC found on its inspections include:
• Staff administering medication, including controlled drugs like methadone, without the appropriate training or being assessed as competent to do so.
• Staff giving paracetamol to people within their care more frequently than every four hours despite them already having, or being at a greater risk of having, liver damage due to their heavy alcohol use.
• Staff not having planned how they would manage a person’s epileptic fits during their withdrawal (e.g. by prescribing anti-seizure medication) despite knowing from their medical history that they were at risk of having seizures.
• Staff lacking appropriate training in basic life support, consent and mental capacity and safeguarding.
• Some units carrying out Disclosure and Barring Service (DBS) checks for newly employed staff but not at routine intervals afterwards.
CQC required all of the providers that were in breach if regulations to improve.
Some providers already have improved and CQC will be re-inspecting the others to ensure that they have done so too.
Four of the services are no longer operating following the concerns raised by CQC on its inspections.
In September 2017, CQC was given additional powers to rate independent substance misuse services as Outstanding, Good, Requires Improvement or Inadequate, in the same way that it already does for NHS hospitals, GP practices, care homes and other services. CQC expects to begin to rate substance misuse services from spring 2018.
Dr Paul Lelliott, Deputy Chief Inspector of Hospitals (lead for mental health) at the Care Quality Commission, said: "Based on our inspections over the last two years, we are deeply concerned about how people undergoing residential-based medical detoxification from alcohol or drugs are being cared for in many independent clinics across the country.
"While we have found some services that are providing good care and we are beginning to see improvements, all providers need to review their practice so that we can be assured that they are delivering safe and effective care.
"Detoxification under clinical supervision is often the first stage of a person’s addiction treatment. It can be a difficult, unpleasant and sometimes, risky experience. It is vital that providers get this right to support people’s onward rehabilitation and recovery.
"We have been given additional powers to rate independent substance misuse services. This increased transparency will help the public and local commissioners to understand the quality of these clinics more than ever before and to drive up the standards of care they provide. We will launch a public consultation on how we will go about this work next year."
In 2015/16, 2,622 people received medical detoxification from a residential rehabilitation service in England – this is around 1% of the 288,843 people in drug and alcohol treatment as a whole. Successful medical detoxification, which can take around 5 to 10 days, often then leads to further rehabilitation and recovery support, such as through psychosocial interventions – these can be delivered in residential or community-based services, depending on the person’s needs and preferences. The services are commissioned mainly by local authorities with people also able to pay privately for treatment (i.e. as self-funders) too.
CQC developed its briefing with Public Health England, which supports local authorities to commission alcohol and drug treatment services.
Rosanna O’Connor, Director of Drugs, Alcohol and Tobacco at Public Health England, said: "Our evidence review of drug treatment services earlier this year found they were largely performing well. But we welcome the light this report shines on the clinical practice in some residential detox services, which were falling short of keeping those in their care safe and providing the best springboard for recovery.
"While residential detox makes up a small part of the overall treatment system, seeing about 1% of all in treatment, they do have a vital role. It’s crucial these services are in line with best practice, as the Clinical Guidelines on drug treatment clearly sets out. This helps ensure not only safety but gives some of the most vulnerable and disadvantaged people the best chance of getting their recovery on track.
"PHE has already been working with these services to help them improve and we will continue to provide this support."
Professor Colin Drummond, Chair of the Addictions Faculty at the Royal College of Psychiatrists, said: "The CQC report on residential drug and alcohol detoxification makes for sobering reading. The Royal College of Psychiatrists is concerned about the scale of the problems with quality and safety. It shows systemic failings in the way these services are provided and that people undergoing detoxification are being exposed to unnecessary risks.
"Detoxification from drugs and alcohol is not a trivial undertaking and carries risks even in well-resourced services with adequately trained clinical staff. These residential services treat the most vulnerable patients, who mostly have complex physical and mental health problems alongside their addictions. Potential risks include severe alcohol withdrawal including epileptic fits and hallucinations, suicide risk, and risk of prescription opiate drug overdose. Therefore it is essential that staff looking after these patients are properly trained, follow national clinical guidelines, and have appropriate 24-hour medical cover. The CQC report shows that in many cases this is not happening."
