We carried out a review of the data available to us about Yeldall Manor on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Yeldall Manor, you can give feedback on this service.
Yeldall Manor is a male only Christian substance misuse residential rehabilitation centre that provides an abstinence-based programme. It does not provide detoxification programmes. It previously had 25 beds, but it is being converted to provide 21 en-suite single rooms.
We rated this service as good overall because:
However:
We do not currently rate independent standalone substance misuse services.
We found the following issues that the service provider needs to improve:
Since our previous inspection, there had been some improvements to medicine management processes but there were still gaps in process and policy around the prescribing and administration of medicines that did not fully assure us that clients would always be kept safe from harm. There were gaps in medicine charts with no explanation recorded. Since our previous inspection the service stocked take-home naloxone medicine but staff were not trained to advise the client in its safe use.
Staff training was not always adequate to enable them to carry out their roles safely. Staff competency was not regularly reviewed in respect of medicine administration or in the completion of withdrawal assessment and measuring tools in line with provider policy. We saw evidence of tools used to assess withdrawal symptoms not being used in line with clinical guidelines.
Since our previous inspection, client care records remained separate and did not cross-reference each other. However, the provider had made progress in addressing this and had a test site in place for a new electronic case management system.
Since our previous inspection staff now completed risk assessments after admission, however, these did not always reflect health or risk information contained in the pre-admission risk assessment. Care plans did not consistently reflect physical health needs.
Prescribing doctors completed a medical assessment on admission for detoxification clients only, but this was not holistic and did not include questions on safeguarding, mental health, capacity, social care needs or a full injecting history. The service received a lot of key information pre-admission from GPs and other relevant health, probation and social care bodies.
There was no multi-disciplinary team meeting in which all staff could review and discuss patient care.
The service had not audited infection control, prescribing, medicine charts or care records. Yeldall Manor commissioned external quality inspections and sought to drive improvement based on these recommendations.
However, we also found the following areas of good practice:
Clients told us the care they received was exceptional and gave them opportunities to rebuild their lives. The programme included a wide range of employment training and volunteering opportunites in the local community and through small business enterprises on the same site. Clients completing the programme also had access to move-on accommodation.
Peer support was included in the structure of the programme. Clients were assigned another client to help them settle into the programme and there were opportunities to make changes to the service through community meetings.
The service was part a group of independent rehabilitation centres where clients could be placed as an alternative to Yeldall Manor if the placement broke down.
Yeldall Manor fundraised and offered a bursary to financially support clients.
Outcomes for clients were good. In the 12 months prior to our inspection, 16 of 17 clients had successfully completed detox treatment with the 17th client undergoing detoxification treatment at the time of the inspection.
There was a clear exclusion criteria and the service did not accept clients that would not benefit from the ethos of the service or where staff could not ensure a safe environment.
Since our previous inspection, Yeldall had instigated quarterly governance meetings and two new posts had been developed to recruit two staff members to focus on governance, policies and audits.
Staff felt happy working at Yeldall and felt there had been a recent improvement in their feeling able to give feedback and input into service development.
Storage and disposal of medicines was well-managed and doctors prescribed and managed detoxification medicine safely and followed national guidance. Since our previous inspection the service had processes in place to report, record, act on or monitor significant events, incidents and near misses in relation to medicines.
The service ensured that all clients accessed physical health care via a local GP practice and a sexual health nurse visited the service regularly to provide blood borne virus testing and treatment.
Since our previous inspection the service had set up policies and an internal system to record any incidents or safeguarding concerns. Staff understood when and how to report incidents or safeguarding concerns.
Staff provided a range of care and treatment interventions suitable for the patient group. These included medicines and detox treatment, therapeutic interventions, mutual aid access and opportunities for training and employment. These followed guidance from the National Institute for Health and Care Excellence.
Staff received regular supervision with 100% of staff having a named supervisor. Staff were able to access specialist training courses in addiction. Mandatory training attendance was good overall. All staff were trained in first aid and received Safeguarding and Mental Capacity Act training via a local authority.
We do not currently rate independent standalone substance misuse services.
We found the following issues that the service provider needs to improve:
The medicine management processes in the service were generally safe but there were gaps in process and policy that did not fully assure us that clients would always be kept safe from harm. There was no process in place to report, record, act on or monitor significant events, incidents and near misses in relation to medicines.
We did not see evidence that baseline blood tests were carried out prior to prescribing medicines for detoxification.
The new clinic room was not connected to running water but the provider recognised that this was a high priority.
There was no incident policy or separate recording of any safeguarding concerns that meant that these incidents could potentially be missed.
Records could not be easily accessed as they were split up and kept in several separate places. This meant that key risk information was not readily accessible.
Clients were risk assessed prior to admission to Yeldall Manor. However, risks assessments were not updated or reviewed at any point while the client was under the care of the service. This meant that any escalation in risk was not formally recorded in a way that would make key information readily accessible to other staff members. There were no risk assessments in place for clients going on weekend leave or risk management plans for unexpected treatment exit.
There was a lack of audits undertaken to review and improve on aspects of care and treatment, which the provider acknowledged. There were no audits completed for infection control or to review whether prescribing was in line with national guidance.
Mandatory training for staff was limited in range. The percentage of staff who had received an appraisal in the previous 12 months was 64%. Senior managers were taking steps to address all of these issues.
However, we also found the following areas of good practice:
The staff audited the quantities of medicines on a regular basis and had good processes to account for all medicines on site. There was good staff awareness of and monitoring of withdrawal symptoms. The doctor assessed clients on pre-admission with a full assessment within 24 hours to assess their appropriateness for alcohol detox. The service supported clients to register with the same local GP within 48 hours of admission
The provider reported that there were no safeguarding incidents over the past 12 months. Staff had an awareness of safeguarding and knew how to escalate any concerns. There were operational policies in place for safeguarding adults and children at risk.
The provider had a duty system with four senior managers rostered to be on call 24 hours, seven days a week outside of working hours and the prescribing doctor was available 24 hours. Staff were able to identify who to contact in the event of urgent client need or an emergency.
All of the staff and volunteers at Yeldall had Disclosure and Barring Service (DBS) checks or the relevant national criminal records checks appropriate for their country of origin.
The service provided a work based programme and training for clients. Clients had the opportunity to be interviewed and then trained by staff for jobs within Yeldall Manor. Clients told us they felt comfortable in the environment with lots of space and rooms to allow clients the option of more quiet time if needed. There were a range of leisure options for clients to access.
Clients told us they were treated with compassion, respect and kindness and that they had the opportunity to influence change. Clients told us they knew how to complain and this was included in the client’s handbook on admission.
The provider offered a bursary for those who could not get local authority funding and was exploring a new way of funding such as ‘Social Impact Bonds’ that the provider hoped would make them more responsive to clients’ needs.
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.
A registered manager was in post who was supported by a Board of Trustees. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.
Yeldall Manor provides residential psychosocial treatment for up to 24 men recovering from drug and alcohol addiction. People stayed at Yeldall Manor for six months to a year. At the time of our inspection 19 men were using the service. Psychosocial treatments include certain forms of psychotherapy (often called talk therapy) and therapeutic social and work activities.
The service had a Christian ethos and people told us this created shared values and a sense of community. This was understood by all the staff and people we spoke with. Though people agreed to attend Christian led activities when they entered the programme, they were free to practice different religions as well. People took part in a structured work programme as part of their recovery. They told us this supported them to remain occupied, feel useful and develop new skills. We received overwhelming evidence from social workers, people and staff that people’s needs had been met and positive outcomes achieved.
The service provided a highly structured treatment and work programme. People were assigned an addictions counsellor as their key worker who supported them to plan and review their treatment goals. People received a treatment programme that addressed their medical, social, psychological and spiritual needs in line with national quality standards. Though the programme was structured and strictly implemented people told us they set their own recovery goals with the support of their counsellors.
However, the information in people’s recovery plans did not always reflect all the support provided to ensure people had a comprehensive record of all their treatment activity and how they would be supported to reach their recovery goals. The absence of a comprehensive recovery plan detailing people’s treatment and progress meant people’s needs and preferences might be overlooked. It might not be clear to people which needs would be addressed in the psycho-social treatment. Relevant agencies might not be involved when required or some people may have to extend their stay because their recovery plans had not been reviewed and their treatment adjusted as their needs changed.
People and their social workers praised the staff and the positive outcomes people achieved through the treatment programme. People consistently told us they had received care at Yeldall Manor from thoughtful, kind and sensitive staff. They told us Yeldall Manor felt like home. Staff were appropriately trained and supported to undertake their roles effectively. Staff we spoke with were passionate about the work they did and celebrated people’s achievements.
The provider was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). People at the home were able to consent to their treatment and the restrictive house rules. They could leave the programme when they chose.
The provider worked with local GP’s who had sufficient knowledge and experience in detoxification treatment to be able to oversee people’s detoxification safely. People were supported to manage the physical and mental symptoms of detoxification.
People told us they felt safe at Yeldall Manor and did not experience discrimination, harassment or bullying from staff or other people living in the home. People were treated with respect and trusted that the provider and other people on the programme would keep their information confidential. The provider ensured that people could raise safety concerns and complaints. People were satisfied that the registered manager would take action to resolve their concerns.
People and staff told us they received clear direction from the registered manager and understood their role and responsibilities in the service. The Board of Trustees supported the register manager to manage the service through regular meetings and ensuring resources were available as needed.
The provider remained informed of developments in addictions treatment and used this information to improve the quality of the service. The registered manager listened to people’s views and had acted on their feedback to make changes to improve the quality of the service. The registered manager worked closely with the Board of Trustees to monitor any risks to the service.
We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.
Admission assessments were comprehensive and explored people's histories and expectations of treatment. Input was sought from outside agencies to feed into people's recovery plans. Risk assessments identified possible risk and how to reduce risk.
The provider had an effective system in place to ensure pre-employment checks were undertaken for potential staff. The provider had an effective system in place to ensure complaints were dealt with to a satisfactory standard.
Some people we spoke to had applied to Yeldall Manor because it offered a therapeutic programme that included resettlement and provided longer term support and the opportunity to relocate. One person said 'It's a really good place'. Another person described the programme as 'very personalised'.
People told us that were able to approach staff with any questions they had regarding the programme and their treatment, and they were involved in the delivery of their care and treatment. People told us that they felt safe at the service and would be able to speak to staff about incidents of abuse or harm.
People who used the service told us that there were enough staff to meet their needs. Staff members we spoke to confirmed this.
People who used the service and staff were asked for their views about care and treatment and these were acted upon. There were a variety of mechanisms in place to achieve this which included, weekly residents meetings, daily staff meeting feedback questionnaires from people at set points during their treatment. These showed good levels of satisfaction.
We spoke with five people, who all told us they received information prior to admission.
People told us that were able to approach staff with any questions they had regarding the programme and their treatment, and they were involved in the delivery of their care and treatment.
The majority of people told us that they were treated with dignity and respect and that activities they were offered were appropriate to the stages of their recovery.
Everyone we spoke with was very complementary about the staff.
People told us that they had plenty of opportunities to get involved in having their say about how the service was run.
They also told us that they were confident that if they reported any problems, they would be dealt with promptly and effectively.