Addiction Today

AN INSPECTOR CALLS – ON RESIDENTIAL REHAB

STAR RATINGS AND RESULTS FOR TREATMENT SERVICES

There was great concern among residential rehabilitation services when the Care Standards Act 2000 came into force. Would the sector be discriminated against, even decimated? DAVID FINNEY of the Commission for Social Care Inspection reports

This article was published in Addiction Today journal, March 2008

Residential rehabilitation services have not only survived the Care Standards Act 2000 but have demonstrated high standards of practice which have been reflected in complimentary inspection reports. No doubt articles in Addiction Today, pressure from treatment-centre representative EATA and guidance from the National Treatment Agency for Substance Misuse helped this process. Meanwhile, inspectors in the National Care Standards Commission and its successor body, the Commission for Social Care Inspection, received training, participated in learning sets and utilised guidance specific to this sector.

Latterly, the NTA has surveyed retention in residential rehabilitation services. It has drawn out factors which improve performance and outlined the sector in terms of “models of residential rehabilitation for drug and alcohol misusers”.

So let’s highlight areas where residential rehabilitation services perform well in the delivery of care – as well as some areas where the sector could improve. I will also identify changes in the wider social-care field as well as the treatment sector which will influence the direction of practice and commissioning. I will comment on these and offer pointers on how to adapt and embrace these changes.

Residential Rehab compared with other CARE sectors.

In a recent survey undertaken by the CSCI, residential rehabilitation services were compared with all the other registered residential services for adults across the country. These other services provide care for people with learning disabilities, mental-health issues or physical disability, for example. Key standards were identified and compared across the 18,000 care homes registered with CSCI.

The encouraging news is that residential rehabilitation services exceeded the national average by some way. They met the key standards on 86% of occasions, whereas the national comparator for all services was 82%. Far from being the poor relations of residential care, the rehabilitation services are in reality leading the way in terms of providing good-quality care.

STAR*** RATINGS WILL BE REVEALED.

In the sector, there are many “top performers”. This can be demonstrated by the fact that 56% of services achieve over 90% of the key standards. This compares with 43% across other sectors.

The implication is that when the “star ratings” of care homes is introduced in April 2008, there is strong likelihood that a high number of services will be rated as “good” or “excellent”. These ratings will be publicly available so people hoping to come into residential rehabilitation or the purchasers of services will able to see which are the top performers. As of April, this information is available on the CSCI website.

In what ways do residential rehabilitation services demonstrate that they are providing a good service? How is this useful for people who use the services?

Outcomes for people USING services.

This past year, CSCI moved from concentrating on standards toward looking at outcomes for people who use treatment services. Inspectors have been asking the question “What is it like living in these services?”.

Far from looking only at inputs such as the physical environment, health & safety and documentation, inspectors have been exploring the quality of care and the experience of people living in each service. This is an area where residential rehabilitation services score highly.

What does residential rehabilitation do particularly well? I have selected some key areas where the sector provides good-quality care. Examples of good practice are highlighted through direct quotes from inspection reports.

reclaiming lives.

The most striking result comes in the area of “living a fulfilling life” where the outcome was met on 97% of occasions.

Inspectors comment on matters which are central to a person’s treatment and recovery. They quote people living in the services who say “This is an excellent programme, much more challenging than I have previously experienced” and “I have really started to look at my life and how I need to change”. Others have said that “This programme has saved my life, and helped me help others to save their lives… I am happy with the person I am, I actually like me, I don’t have to pretend to be somebody I am not… the future belongs to me”.

In my view, this is absolutely central for a person wishing to achieve a good recovery. So it is particularly heartening to see that the sector is seen to promote fulfilment so well.

When looking at documentation, it is also interesting to see that inspectors found that plans kept by the services show clear progression and achievement of agreed goals. This is important confirmation that fulfilment is promoted and achieved. In turn, this provides good evidence for placing/purchasing bodies, such as Drug/Alcohol action Teams, that the services are achieving the aims of the placement and so worth purchasing.

Other aspects of fulfilment which inspectors comment on are activities, relationships, and a sense of re-integration into society. Inspectors note that “Activities are chosen to contribute to the sense of community in the service and to promote the work of recovery”.

Also they comment that the people who use services are “encouraged to maintain and rebuild relationships which are appropriate”.

Finally, one programme is described as “requiring residents to take more responsibility for planning a future beyond (the service)”.

Inspectors often experience a sense of engagement with the people living in the services they visit. For example, one inspector commented that “the atmosphere was vibrant and residents readily discussed life in (the service)”.

Choice and Control.

This is an area where it might be thought that people in residential rehabilitation lose out due to restrictions placed on them and requirements to attend programmes. Instead, this scored highly in CSCI inspection reports – with the standard being met on 90% of occasions.

Inspectors reported that “People are supported in making their own decisions and in becoming responsible for their own recovery”. When entering a service, it is important that restrictions intrinsic to programmes are spelt out in advance and agreed with the prospective resident. One person commented that “I got the booklet about the service and was interviewed by the key worker before I decided to come”.

The standards ask for a Service User Guide and this has been produced and used effectively throughout the sector as a demonstration of an increasing openness to the choice, control and responsibility exercised by people entering rehabilitation. There is a range of treatment approaches on offer in this sector, so it is important that both people entering treatment and commissioners are given good information about the philosophy behind say, 12-step, therapeutic communities or harm-reduction approaches. This enables them to choose the appropriate service for their needs. Success is more likely to be achieved this way.

Health & Well Being.

Compared with other sectors, the residential rehabilitation sector again performs well. Overall, the standard was met on 87% of occasions whereas the national comparator is 83%.

This means that people receive support in the way they prefer, their physical and emotional health needs are met and there are good medication procedures in place. Also, their assessed and changing needs and personal goals are reflected in their individual plan.

All of these factors add up to good packages of care being delivered in a way which is useful to people using residential rehabilitation services. Inspectors often comment that “people using services are involved in developing and reviewing their care plans and are encouraged to reflect upon their life’s events and how these have affected them”. Another external stakeholder added that “One of the things that this service does well is planning and implementing care for service users”. Most services recognise that care plans are subject to very regular review, sometimes daily, and this is recognised and positively viewed by inspectors.

Where detoxification is undertaken, positive comments are made about the medication regimes that are crucial to recovery.

In addition, the food on offer in residential rehabilitation is part of the inspection process. One inspector explained that “The provision of a healthy diet and promoting a healthier lifestyle plays an important role in this unit as the programme is designed to overcome the often chaotic lifestyle of the service users”.

Concerns and complaints.

It is well recognised that people in residential rehabilitation services can be vocal when it comes to expressing their needs and making complaints. The evidence is that they felt listened to by their key workers and managers in the services.

This standard was met in a high number of instances: 89%. There are two major reasons for the high score. The first is the success of “residents’ meetings” which were found to be regular (most often weekly), well run, open, fair and  well recorded.

Secondly, there were good relationships with staff who showed good listening skills in an open relationship.  It is my view that services which listen to concerns and complaints in a constructive way are able to improve the way they deliver their treatment programmes.

Furthermore, inspectors found that the procedures which protect patients from abuse were working well in 81% of services compared with the national average of 79% of services.

Sometimes there were alterations needed to ensure that all the local safeguarding information was accurate.

So far, so good. On the next page, we investigate the areas which need improvement.

Areas to improve.

Naturally, there are areas where CSCI inspectors felt that improvement was necessary. Following these recommendations will enable the sector to ensure that it is providing the highest quality of care possible.

The first area was in the recruitment of staff. For example, there were some instances where two references for new staff had not been taken up or where staff had begun work before the CRB criminal-records bureau check had been completed. These are procedural matters which can be improved when good auditing and tracking arrangements are in place. People need to be sure that the staff supporting them are safe through proper checking. Having said this, the standard was met on 69% of occasions.

The next area for improvement was the keeping of health and safety policies and procedures. That was also met on 69% of occasions. Sometimes this was down to fire-safety drills not carried out regularly enough, other times it was to do with following up environmental-health recommendations on food labelling or storage. Usually these were minor points but nevertheless important to the health and welfare of people living in services if they not put right.

For the future.

A key change to inspection will mean that each service will have a “quality rating” published from April 2008 onwards.

This will mean that prospective residents, commissioners, care managers and the general public will know if a service has been assessed as “excellent, good, adequate or poor”. In its work with local authorities, CSCI will be asking hard questions where poor or even adequate services are being routinely purchased.

The Healthcare Commission and NTA Joint Service Review for Substance Misuse will look specifically at Tier 4 services and decide if local partnerships as well as individual services are integrated and effective. The improvement planning which results will be key to the provision of quality services across the sector.

Further to this, wider governmental policy initiatives will soon have an effect on this sector. Of prime importance is the “personalisation agenda” promoted by the Department of Health. The aim is to move thinking...

1. From “passive client to active citizen”
2. From “Welfare to well Being”
3. From “Dependence on services to independence through services”
4. From “State donates to a state where people control and choose”.

This will lead to individual budgets for people using services and a culture where quality is determined by people who use services.

This approach will be a challenge for the residential rehabilitation sector. But it is my view that this is not as radical as it might appear at first sight. People entering residential services are making an “investment” in their future recovery. Currently, they mainly think of the emotional and relational resources they are committing to this task. In the future they could be more fully involved in the financial implications. This will be a concrete demonstration of their commitment to change.

In my view, enabling people living in services to participate even more actively in their recovery is an extension of the active participation in therapeutic work, similar to the “sign up” required in a therapeutic community, and in line with the rigorous self-assessment required of someone working through a 12-step programme.

The next steps will involve communicating with commissioners that this is what is happening in the residential rehabilitation sector.

Finally, there will be a new-look regulator in April 2009 called the Care Quality Commission. This will involve a merger of the HealthCare Commission, the Commission for Social Care Inspection and the Mental Health Act Commissioners. To effect this change, a new Social Care Bill is currently proceeding through parliament. I will bring you news of these developments on another occasion!

Conclusion.

The residential rehabilitation sector has much to be proud of in the way it delivers high quality of care. People who use services can be reassured that care is delivered in a way which promotes their recovery, enables them to live a fulfilled life and assists them in regaining choice and control in their lives. The future for residential rehabilitation depends on how well the links are made between the new social care agenda and provision on the ground.

References:

D Boyd: Death of Rehabs? in Addiction Today Sep/Oct 2001.

CSCI: Guidance for Inspectors of Residential Rehabilitation services for people recovering from drug or alcohol addiction (www.csci.org.uk)

NTA: A national survey of retention in residential rehabilitation services, June 2005.   

NTA: Models of residential rehabilitation for drug and alcohol misusers, October 2006.

SUBSTANCE MISUSE IN MAINSTREAM CARE SERVICES

Where does someone who has a learning disability and an addiction go to receive help? What happens when an elderly person with a life crisis reacts by misusing alcohol, and needs help to stay in their home? Is there any recognition of their alcohol problem?

By DAVID FINNEY, provider relationship manager – Commission for Social Care Inspection

To address some of these issues, the Commission for Social Care recently arranged a series of seminars, briefly reported in the November 2007 Addiction Today. This brought together key stakeholders in the residential and domiciliary care field, including large corporate companies with services across the UK. Under consideration was the likelihood that there are people receiving mainstream care services whose addictions are not being treated.

By exploring two relatively overlooked areas  – mental health and the elderly – it might be possible to highlight some of the reasons behind this and point towards possible solutions.

The issue of “dual diagnosis” in terms of mental health and substance misuse is a well-worn path. This does not mean to say that people in mainstream services receive help for their two problems in a completely ‘joined up’ way. At the CSCI seminar, Turning Point presented its recently published Dual Diagnosis Guide to Good Practice which highlighted areas where improvements can be made.

Learning Disability and addiction

Mike Delaney of Stepping Stones, a care home provider in Gloucestershire, explored this eloquently. He revealed two case examples which bring this area into sharp focus.

The first was an extremely vulnerable female with learning disabilities who was addicted to crack cocaine and working in the sex industry to fund her habit. She expressed a desire for help with her addiction but no one could be found to fund the specialist help she required. Mainstream residential care could not hope to meet the range of needs she was presenting.

A second example was of a vulnerable male with learning disabilities who was working as a rent boy, was HIV positive and hepatitis C positive. He was also misusing illegal drugs. No service provider would assume responsibility for his care.

Do we know how widespread this problem is? The most recent review of research has been undertaken by Adam Huxley et al at the University of Birmingham. This highlights the following:

• prevalence might be up to 2% of the general learning-disabled population using substances problematically
• misuse of alcohol among people with learning disabilities is about the same as non-cognitively impaired counterparts
• mild learning disabilities can be, in itself, a risk factor for adolescents who engage in binge drinking.

A rough estimate is that there could be 50,000-100,000 people with learning disabilities who are also problematic users of drug or alcohol. This means that, both in the 6,670 registered residential services and in the wider community, there could be a significant need which is not being met.

Delaney also pointed out that there might be secure units around the country in which adults with learning disabilities are held having committed schedule-one offences while under the influence of alcohol or drugs.

What are the barriers to this need not being met? The following facts spring to mind as possible causes.

• Assessment of people in the community with learning disabilities is unlikely to include the issue of substance misuse. So it is probably going unrecognised by mainstream service providers.
• It is likely that any negative consequences of problematic substance misuse will be deemed to be “challenging behaviour” for example, and dealt with on a behavioural level without addressing underlying causes.
• Staff in mainstream residential care services are not usually trained to screen for substance misuse.
• Registration of care services steers providers to register just the “primary need” which might lead to substance misuse being overlooked.
• Funding streams are either in the learning disabilities budget or under the auspices of Drug Action Teams who might not have a remit for the wider needs such as learning disabilities.
• Treatment for addiction in residential settings often requires a high level of cognitive ability to benefit fully from the programme on offer – a mismatch for someone with learning disabilities.

Delaney has developed the ‘Dorabella Model’ which, he believes, is well suited to meeting the complex needs presented by this client group. His description is that the model is “fully person centred and behavioural in nature. It addresses all areas of substance misuse, culminating in a bespoke service meeting the individual needs of service users”. Programme modules address motivation, self-awareness and behaviours linked with substance misuse.  It goes on to address safe and risky thoughts, looking at the consequences of actions and problem solving. The approach offers the potential to meet the needs of this client group in a holistic way. It is hoped that commissioners will soon see that this represents a major step forward in service provision.

There is also a converse challenge for established residential rehabilitation centres to consider whether their programmes can be adapted for people with learning disabilities. The emphasis should be on concrete step-by-step problem solving and management of behavioural changes.

The next challenge would be to convince commissioners and purchasers of services that their service could provide a safe place for vulnerable people with learning disabilities. Under new registration guidance issued by the CSCI, there would not be the need to apply for additional conditions of registration. Instead, this could simply be built into the “statement of purpose” which each service already possesses.

Elderly People and substance misuse

This area could be even more overlooked than the preceding issue. Research is thin on the ground and much alcohol misuse amongst elderly people is probably under-reported.

The UK Inquiry into Mental Health and Well-Being in Later Life concluded simply that “more work is needed to gain a better understanding of alcohol misuse and mental health in later life”.

Alcohol Concern’s study found that, of people aged over 60 years old, about 23% of men and 8% of women endangered their health by drinking above the recommended guidelines. This means that over 2.5million older people are drinking at least five days a week. Furthermore, Alcohol Concern states that it is likely that this level is under-reported and that it might go undetected for longer than other age groups.

What is the significance of the problem for elderly people? With the changing demographics – a growing number of older people in the population – is this likely to be a growing problem? Alongside the increasing availability of alcohol, it seems to be an issue which will affect a rising number of older people in years to come.

How might problematic drinking first emerge among an older age group? What factors might lead to it being sustained?

Specific triggers can prompt an episode of alcohol misuse, or even the beginnings of an addiction to prescription drugs. These are highlighted by Alcohol Concern as:

• bereavement, especially of family or close friends
• loneliness and social isolation
• failing physical health
• loss of social function, income, skills.

All the above can lead to feelings of worthlessness and a lack of social and emotional support at times of vulnerability. So it is not difficult to see how someone could misuse alcohol, for example as a way of dealing with the emotional pain associated with such life changes in later years.

Alcohol misuse can also exacerbate health problems experienced by elderly people. So if a person is misusing alcohol, studies show that the following can be a consequence:

• earlier onset of dementia
• anxiety or depression
• increased likelihood of falls
• increased risk of hypertension or strokes
• self neglect, poor nutrition, hypothermia.

If these problems are noticed when elderly people are living in their own homes, it is likely that that they will be considered to  be  problems linked with  ageing rather than indications of problems with alcohol. This raises a challenge for domiciliary services to appropriately assess the wide range of needs and their potential causes.

Mick Davies, who is development manager of addictions services for the Huntercombe group, addressed this at the CSCI seminar.  He focused on the incidence of alcohol misuse in residential care for elderly people.

First, he issued the challenge to homes to develop an alcohol policy for residents in their ‘statement of purpose’. He questioned how often someone’s alcohol consumption is assessed. For some, it could be an unproblematic aspect of their life; they would like the option of continuing their moderate consumption of alcohol. However, if it is not asked on admission, residents might be denied this aspect of their lives that was a feature for many years. 

Second, he challenged the sector to consider the use of validated screening tools which would allow accurate assessment and planning of care. He argued that more specialised assessment could be undertaken if there was a point when concern was raised about use of alcohol.

Third, he challenged homes to consider the training of staff to include drug and alcohol awareness in their core training programmes. If this does not happen, he warned that substance misuse might continue to go unrecognised or incorrectly treated.

Fourth, Davies challenged homes to make contact with specialist community addictions services, so that appropriate help could be accessed when required.

Finally, he concluded that a key feature in a care planned approach was working with the agreement of the elderly person concerned. Without this, services would be showing a lack of respect and diminish the chances of successful treatment.

The wider challenge is for community-based services around the country to accept that substance misuse might be a problem for some elderly people, and to consider it in the assessment of their needs as well as in the planning of their care services.

ConclusionS

• Substance misuse    among the learning disabled and elderly population is probably a “hidden phenomenon”.
• Issues of substance misuse can be “masked” by other problems associated with each client group.
• Specialist services for the treatment of addictions among these population groups are probably underdeveloped.
• More research is needed to establish both incidence and effects of substance misuse.
• Commissioners and service providers need to be challenged to meet the complex needs of the elderly and learning disabled client groups.

References:

A Huxley et al (2005): Substance misuse and the need for integrated services in Learning & Disability Practice vol 8 no 6 July 2005.

Alcohol Concern (2002): I don’t mind if I do.

Turning Point (2007): Dual Diagnosis: A guide to good practice.