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”.
So, what is the story this year? Has this position been maintained? What factors could affect the survival of residential rehabilitation services?
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.
Safeguarding
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.
Fulfilment
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.
Quality Assurance
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.
Future Improvements
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:
New Standards
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!
References
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.
Whilst I do not dispute the effectiveness of rehab, I am disappointed that addiction today seem to be promoting "rehab at all costs"
Is 'addiction today' suggesting that local authorities and the NTA support rehabs in order purely that they stay open? You run a rehab closing article which reports that 18 rehabs have closed this year. Were all these units producing measureable outcomes for service users? Were all these units treating users with dignity, respect and privacy as well as preparing them for drug free positive lifestyles or does that not matter? Is it the fact that they are closing that is more important?
It is sad that in the economic climate in which we are living public spending is the first to suffer. Local authorities are closing care homes for older people, schools are closing, community facilities such as swimming pools etc are closing. All public services are faced with extremely difficult financial environments and whilst accepting that cheapest is not always best many local commissioners do not now have the luxury of providing 5* drug treatment.
If addiction today feel the need to continue to play the blame game then I'm afraid the finger of blame needs to be directed at Central Goverment who continue to squeeze public expenditure
Posted by: Derek Wilson | March 03, 2009 at 02:51 PM
I have no doubt that the results would be even more spectacular if clients were referred before the severity of their addiction reached the existing levels of'qualification' for residential rehab.
Posted by: Peter O'Loughlin | March 03, 2009 at 06:15 PM
To Derek Wilson,
Nowhere has Addiction Today even remotely suggested the concept of "rehab at all costs".
Only 2% of people desperately needing help to turn around their drug-damaged lives, and seeking that help from the system overseen by the NTA, managed to get referrals to rehab last year. That means 98% of those the NTA claims are "in treatment" were referred elsewhere. That is not a continuum of care. Most importantly, as you say is the case with you, they were not necessarily clinically-driven decisions.
Also, many public-sector workers have and continue to refer clients to, say, NHS detox costing £1,700 per week rather than detox in a rehab at a fraction of the price.
Good rehab is, in fact, cost effective as well as clinically effective.
4 weeks in a carefully chosen rehab costs about the same as a person on, say, methadone for a year. That's if the methadone user gets no psychosocial support. But the user could be on methadone for a decade, a quarter century: 10-25 times the cost of rehab.
In the meantime, long-term use of methadone, like any other powerful drug, gradually impairs the user - including ability to make future choices, such as giving up drugs. That is not even mentioning the inexorable rise in methadone-involved deaths.
I am not saying that methadone should not be used - rather, that we need good practice, particularly in the recognition that it is a form of engagement, an adjunct treatment. Harm reduction methods should ideally work towards the goal of becoming drug free, and lead clients towards that goal. You write as though the harm reduction and abstinence were two different entities rather than part of the whole.
I don't understand your question that closure is more important than successful outcomes. The closures are so regretful because the vast majority of organisations did produce successful outcomes. Also, the government review on this web page highlights the high standards of rehabs.
You seem to have no experience of recovery. If you wish to waive anonymity and contact the Addiction Today office, we can arrange a visit to a treatment centre so that you can witness life transformations first hand, as well as learn about cost effectiveness and long-term followups. Meeting dedicated staff can also be a life-enhancing experience.
Public spending... I am reminded that us taxpayers must pay £1TRILLION to platinum pensions of the public sector. A tiny percentage transfer of funds from that, and there would be no need to debate funding for anyone who needed treatment. All decisions could be clinically driven for the benefit of users, their families, their employers/ future employers,the criminal-justice system, the healthcare system and society at large.
Posted by: Deirdre Boyd | March 03, 2009 at 08:35 PM
"5* drug treatment."? I don't know where Mr.Wilson gets the idea of 5 star drug treatment for addicts. I am,unfortunately addicted to Methadone, a disgusting drug that my Gp precribed in all honesty because i got caught up in the Heroin trap,albeit temporarily. I was on 100mls a day at one stage but managed to claw my way down to 30 mls on my own volition. If it wasn't for the so-called 5* drug treatment centre i am going to god only knows how i would get off that last 30 mls. Of course there are other issues that affect me in why i got onto Heroin then Methadone in the first place and i hope my brief spell in the residential centre will help me come to terms with that. I also have good after care in place thanks to the local services up here in Edinburgh. So,when one ways up the cost of a Methadone script for, say 5+ years compared with a capital expenditure of around £5-7,000 in all,i would say that the residential rehab wins hands down on a penny for penny basis of course. The only proviso i would make to that statement is the provision of proper and effective aftercare that must be in place after the patient come out of the rehab.
Thank god i stay in Edinburgh,Scotland and thank god we have some of the best drug workers in the country working for us.
Posted by: derek Donaldson | May 12, 2011 at 05:23 PM