RESIDENTIAL REHABILITATION: WHAT’S THE STORY?
The government’s Commission for Social Care Inspection and the NTA carried out a review of treatment services last year – inspector David Finney reveals findings that “residential rehabs outstrip other sectors in every outcome group we measure”.
Print-friendly version: Download Addiction Today 117-Tier4review
Last year [in Addiction Today journal], I brought news that residential rehabilitation services delivered good-quality care compared with other care sectors inspected by CSCI, the Commission for Social Care Inspection. Since then, there has been a year of activity when Tier 4 services have come under scrutiny from the National Treatment Agency for Substance Misuse in its Improvement Review. There has also been much debate about their integration with the whole drug treatment system, their largely abstinence-based philosophy and their position in the market place.
The story is that the news this year is even better than last year. In a statistical survey of all the residential services registered with CSCI, residential rehabs have improved over the year and outstrip other sectors in every outcome group we measure.
The following table gives some basic figures which are of interest. The percentages refer to the meeting of national minimum standards for each outcome group.
Outcome groups 2006/7 2007/8 Nat average
Choice & control 90% 94% 89%
Fulfilment 97% 98% 94%
Health & wellbeing 87% 90% 85%
Management, staffing 78% 83% 81%
Safeguarding 80% 85% 81%
Quality assurance 82% 85% 76%
Overall 86% 89% 85%
These results represent a major achievement in terms of delivering quality care for people in recovery. All these outcome groups are important for people residing there – but a few words about each will illustrate the good work done by rehabs during this time.
Choice and Control
Key features affecting choice are the quality of information provided before admission as well as the depth, professionalism and service-user involvement in the assessment process.
Once a person takes the step to be admitted, the extent to which they are able to exercise control over their own decision-making and risk-taking is assessed. Inspectors were clearly convinced that rehabs embedded this in their practice. Furthermore, people in recovery were able to recount their experiences of choice and control in an understandable way.
Health and Wellbeing
Inspectors observed very good relationships between health professionals and rehabs, leading to physical and emotional needs being very well met. In the days of increasingly complex needs being presented by people coming to rehabs, this is very good news.
Care planning is key to this outcome, with active involvement of people receiving the service at both the planning and the review stages particularly commended by inspectors. The philosophy of “person centred planning” is seen as central to rehabilitation as well as linking in well with Local Authority expectations of care planning. This results in the care pathway being more likely to be continuous.
Management and staffing
A safe recruitment process and a high proportion of well-qualified staff reassures people in recovery that they will receive good-quality care when in residential rehab. Of central importance is the calibre of the managers.
Inspectors were particularly impressed with their professionalism, approachability and staff-management abilities. The manager has to go through a rigorous registration procedure with CSCI, thus ensuring that they have a full understanding of the role and accountabilities incumbent upon them. From experience, I would say that a good manager unfailingly ensures a good service and a better outcome for people using the service.
It is important that people in recovery feel safe. This is achieved through a good understanding among staff about how to listen to complaints and when to involve local safeguarding procedures.
The quality of the environment is important in terms of health and safety, hygiene to reduce the risk of cross infection and comfortable living areas to ensure the stay is a convivial as possible. In my view, rehabs have made major steps forward in recent years to bring about these improvements.
It is particularly gratifying to see that the treatment programmes are seen to be delivering good opportunities for personal development. People spoken to by inspectors confirmed that this was the case. People’s rights are adjudged to be respected and the development of their personal and family relationships are seen to be appropriate to their recovery.
This is important to note, as sometimes rehabs are seen as remote. But the evidence from inspection is that rebuilding relationships is well addressed in those that are inspected by CSCI.
Inspectors focus particularly on the quality of the involvement of people using services and on the way in which this feedback is formed into a development plan for the running of the unit. There is now a requirement to complete an Annual Quality Assurance Assessment, AQAA, for registered services. This asks for a self-evaluation of what works, what has improved and what is needed to be done over the next 12-month period.
Inspectors assessed this sector as outstripping the rest of the care-home sector by a considerable margin, illustrating a well-developed ability to be self-reflective and concentrate on continuous improvement.
Star Ratings – more good news!
Homes are allocated an overall quality rating following a key inspection. Increasingly, Local Authorities when they purchase residential services are concentrating on only those services that have a “good” or “excellent” rating.
It is this area which is the best news for the drug and alcohol rehab sector because 91% of all services have such a rating compared nationally with other sectors, where 69% come into this category. Again, this improves on last year when 82% achieved a “good” or “excellent” rating.
In a recent report, CSCI highlighted the fact that 81% of councils use quality ratings in the decision-making process in respect of care homes, so this is bound to affect commissioning practice in this sector also.
It would be unwise to rest on laurels in an increasingly competitive environment. The two specific areas where improvement would be beneficial are highlighted below.
Medication. The importance of completely accurate recording, staff training and proper procedures for PRN and controlled drugs cannot be emphasised highly enough. This did improve during the year so only small improvements are needed going forward. Once in place, people will be completely reassured that their medication needs will be comprehensively taken care of.
Staff recruitment. This also improved during the year. But closer attention to the detail of the recruitment process will fully reassure people that staff have all the relevant checks so are completely safe to work with them.
The Joint Improvement Review undertaken by the NTA, fully supported by CSCI, and published in January 2009, showed that residential rehabilitation services were generally operating well according to the criteria generated for the review. There were some outstanding areas where improvement was required.
The first concerns an evidence-based manual. More attention is needed to procedures to manage the existence of blood-borne viruses. Also, processes for developing employment-related activities were needed in some places.
The second point was about ensuring that policies and protocols relating to exit plans and unplanned discharge are robust.
Both are important areas for the safety of people in recovery at residential rehabs and especially for their ongoing reintegration into everyday life, in my view.
THE Future of regulation:
a new body will emerge in april
On 1 April 2009, the Care Quality Commission comes into being: a merger of the Healthcare Commission, the Mental Health Act Commission – which focuses on the needs of detained patients – and the Commission for Social Care Inspection. This will be followed by a new approach to regulation and a wider brief in respect of substance-misuse services.
THE Future of Regulation:
The Department of Health consulted on this during 2008 and included that “accommodation together with intensive treatment… for people recovering from addiction” as an activity to be regulated. This could extend to “quasi residential” services where the accommodation is provided off-site but is part of the package of care for someone in Tier 4 treatment.
The draft regulations are due to be released this spring followed by “compliance standards” – ie, the detail, to be developed by the Care Quality Commission. There will be further consultation on these proposals by the Department of Health and the CQC, so look out for developments.
Future of Regulation: This year
Meanwhile the intention for the first year of operation is “business as usual”, in other words the same inspection methodology will be in operation and the same body of inspectors will be following this through on the ground. However there will be one major innovation. This is the introduction of “experts by experience” across the country following a successful pilot in the South West and North West. Under this scheme service users accompany Inspectors and focus specifically on the service user experience of treatment.
Future for Tier 4 services
In the NTA’s Improvement Review, there was encouragement to commissioners to integrate residential services with other drug treatment mechanisms. Also, the Commissioning Guidance from the NTA supported the place of Tier 4 services in the provision of an effective local drug treatment strategy.
Overall, I believe that the future is both challenging and potentially very fruitful for residential services, provided they pursue quality, seek to integrate themselves with the rest of the treatment system and continue to hold the person in recovery as the most important piece of the jigsaw. Then hopefully the story will have a happy ending!
CSCI: State of Social Care in England 2007-08, January 2009.
Department of Health: A consultation on the framework for the registration of health and social care providers, March 2008.
David Finney: An Inspector calls – on residential rehab in Addiction Today, March/April 2008.
NTA: Improving the quality and provision of Tier 4 drug interventions – Commissioning Guidance, September 2008.
NTA: Improving services for substance misuse – Diversity, and inpatient and residential rehabilitation services, January 2009.
David Finney is provider relationship manager, sector lead – substance-misuse services, for the Commission for Social Care