Littledale Hall Therapeutic Community

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

This meant people were safe and protected from avoidable harm.

The service was generally safe, clean, well equipped and fit for purpose. Staff assessed and managed risks to clients and themselves well. Staff understood how to protect clients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely administer, record and store medicines. The service managed client safety incidents well.

However, there were some areas of the environment that required maintenance and some infection prevention and control issues identified. Handover notes within the service did not always provide clear updates on outstanding issues or incidents that had occurred.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The evidence showed some shortfalls. The service had not always ensured that incidents recorded during staff handovers had updates or outcomes recorded to ensure that all staff were aware of these.

The service had not had any serious incidents in the 12 months prior to the inspection.

All staff knew what incidents to report and how to report them. There was evidence that incidents were discussed within handover meetings however, there were not always clear updates and records as to the resolution of incidents. During our review of handover notes, we identified incidents that had been recorded but, on subsequent days, staff had not recorded any updates or actions stating how the incident had been resolved or if there were still actions ongoing. An example of this was where a client’s phone had been identified as unaccounted for, although staff understood it was in the client’s possession. The handover notes recorded that the client denied having their phone when staff asked for them to hand it in. There was no follow up or update documented about this in any subsequent handover notes. Staff were able to provide a verbal explanation of the resolution of these incidents and the actions taken. The incidents reviewed were low risk incidents that did not indicate any significant risks to the wellbeing of clients. We were not assured that the recording and documentation of the handover process ensured that all staff would have been aware of these though.

Managers could provide examples of areas of learning that had been identified in the 12 months prior to the inspection and updates as to how changes had been made to the service as a result of feedback. Managers gave an example of how a trend of clients leaving during the second stage of the programme had been identified, and how they had engaged with staff and clients about why this may be occurring. As a result of this review, managers implemented life story work between 2 to 6 weeks of a client’s treatment to involve the clients in deeper work at an earlier stage. Managers reported this had a significant impact on reducing discharges during the second stage.

Staff understood the duty of candour. They were open and transparent, and gave clients and families a full explanation if and when things went wrong. The service had a duty of candour policy. The registered manager stated that no incidents in the 12 months prior to the inspection had met the formal threshold for duty of candour.

The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the client was received to determine if the client’s needs could safely be met. The service had an admissions co-ordinator who managed the admissions process. We reviewed 4 client care records and found there was clear evidence that historic factors had been explored and considered within the initial assessments.

Stakeholders gave positive feedback about the admissions co-ordinator, feeling that they took a sensitive and caring approach throughout, ensuring that clients were treated as individuals and were supported through this process.

Whilst we were on-site during the inspection, we observed a new client being shown around the service with a family member present. Staff and managers interacted with the client sensitively and in a warm and welcoming manner. Managers offered reassurance and positivity towards the client about them entering the service.

The service had restrictions and expectations that clients would be asked to abide by whilst in the service. Managers noted that all clients were informed of these and would be asked to sign a disclaimer as part of their admissions paperwork. Clients were aware of the restrictions and expectation of the service. Clients felt that the service managed these appropriately and fairly.

Managers explained what factors would potentially prevent a potential admission from accessing the service. The service gathered reports and feedback from external professionals to understand the background of these issues when considering if the admission would be accepted.

Staff involved all the necessary healthcare and social care services to ensure clients had continuity of safe care, both within the service and post-discharge.

The service provided aftercare support to clients once they were discharged. We received positive feedback from stakeholders and former clients in relation to the aftercare support the service provided.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Managers explained that the mandatory training for each year was available at the start of January for that year and that staff would be expected to complete the training by the end of February. The training data indicated that the service had been 100% compliant for 2025 and at the time of our inspection, in early February, 56% of staff had already received their refresher training.

The service had a safeguarding policy. Staff were required to sign to confirm that they had read each policy.

The service had 2 recent safeguarding issues in the 2 months prior to the inspection where managers had liaised with the local authority safeguarding team. Managers could explain the issues and the actions that had been taken to address them. The service had identified that additional training in relation to staff boundaries with clients would be beneficial and they were exploring having an external trainer to provide this training.

Staff could give examples of how to protect clients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.

The service had a clear process in place for how visiting in the service was managed and this was communicated with clients and their families.

Mental Capacity Act

Staff received training in mental capacity. Managers explained that the mandatory training for each year was available at the start of January for that year and that staff would be expected to complete the training by the end of February. The training data indicated that the service had been 100% compliant for 2025, and at the time of our inspection, in early February, 56% of staff had already completed their refresher training in the Mental Capacity Act.

Staff we spoke with had an understanding of the Mental Capacity Act, in particular the five statutory principles

The service had not made any deprivation of liberty safeguards applications in the 12 months prior to the inspection to protect people without capacity to make decisions about their own care.

The provider had a policy on the Mental Capacity Act and deprivation of liberty safeguards. Staff were aware of the policies and had access to them.

Managers could provide examples of how and when staff had considered capacity within the service. This included discussions as a staff team to consider and understand decisions made in relation to this, and to provide an opportunity to reflect on these decisions.

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to clients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 4 client care records. Staff completed a risk assessment for all clients and updated these as required. This included plans for the unexpected exit of a client from treatment.

Staff monitored clients for any deterioration in their physical or mental health. The service had strong links with a local GP.

Staff involved clients in care planning and risk assessments. Care plans were personalised, holistic and recovery focused.

Staff communicated with clients so that they understood their care and treatment, including finding effective ways to communicate with clients with communication difficulties. Clients felt informed by staff about the service and the expectations that they had to meet as part of their care and treatment.

Staff enabled clients to give feedback on the service they received. Managers outlined the various ways in which clients could give feedback on the service and were keen to encourage an open and honest community within the service.

The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

During the tour of the building, we observed some areas of work and maintenance that needed to be addressed, including mould on one of the bedroom windows and the lock on one of the bedroom doors not being present. The building was a large, older building which required ongoing upkeep and maintenance. The mould was a known issue. The provider requested that clients monitor the windows as part of their regular cleaning of their bedrooms and supplied cleaning products to assist with the removal of mould. At the time of the inspection, the clients in that bedroom had not undertaken this cleaning which managers had not been aware of.

There was also damage to some of the bathrooms and the ceiling and wall of one of the upstairs bedrooms. The service had identified the damage to the bathrooms within their monthly building review for January with an action that maintenance would review. Whilst observing the client bedrooms during the inspection, there was evidence that the service was taking actions to address any issues with damp or damage to the walls, although this remained an ongoing process due to the building. No clients that we spoke with identified any concerns about the building or safety of it. Following the on-site inspection, managers sent photographic evidence to confirm that actions had been taken to address the issues.

The service used multi-occupancy bedrooms. Clients that we spoke with did not raise any concerns about this.

Staff did regular risk assessments of the care environment. The service had an environmental risk assessment which had been completed in July 2025. The service also completed weekly and monthly checklists to review the environment. The fire alarms had been tested in July 2025 and there was evidence of ongoing fire drills being completed. Whilst reviewing the most recent fire risk assessment, dated August 2025, we observed that 6 remedial actions had been identified that the service needed to address however, there was no specific action plan or record to indicate how the service was monitoring and ensuring that all the actions had been completed. We observed that some of the actions, which included areas such as a lack of fire drills and ensuring fire safety documentation was collated and maintained, had been progressed although we were not assured that the service had appropriate oversight of all the actions.

Medication stored within the service was secure, tidy and well-organised. The service had protocols and policies for the storage and management of medication.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

At the time of the on-site inspection, the service had no vacancies. One member of staff was on maternity leave.

The service had low levels of sickness in the 12 months prior to the inspection, with 31 episodes of sickness totalling 53 days off work. The service noted this was less than 1% of the total staff days at work in this 12-month period.

The service had no staff on long term sick leave at the time of the inspection.

The service had 4 staff leavers in the 12 months prior to the inspection.

The service did not use agency staff. The service utilised bank staff to support and cover as needed.

Managers felt that the staffing levels were appropriate for the service and they continually monitored staffing to ensure there were no issues because of staffing levels.

Clients did not raise any concerns about staffing levels in the service.

Staff received appropriate mandatory training. The training was appropriate for the client group using the service. At the time of the on-site inspection, mandatory training completion figures were low for certain courses however, managers explained that the mandatory training for each year was available from the start of January for that year and that staff would be expected to complete the training by the end of February. Our inspection was in early February and therefore staff were in the process of refreshing mandatory learning. The training data indicated that the service had been 100% compliant for 2025.

The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

There were some infection prevention and control risks that the service had not identified and addressed. During the tour of the building, we observed some furniture which was ripped, torn or damaged. This included a chair which was in one of the client bedrooms and the chairs in the office building. These were potential infection prevention and control risks as they would not have been able to be effectively cleaned in their current condition. Managers explained that the chair in the client bedroom had originally been removed from the building and stated that clients must have brought it back in by themselves. Managers noted this would be removed immediately. The service confirmed that the chairs would be replaced and they provided photographic evidence following the on-site inspection to confirm that this had been done. The damaged chairs had not been identified within any of the service’s walkarounds or reviews of the environment. The service did not have a specific infection prevention and control audit.

The building itself was clean and tidy. Clients were responsible for cleaning the house as part of their therapeutic activities and were expected to keep their bedrooms clean and tidy. Staff checked bedrooms daily to observe if they were tidy and the beds made. Managers advised that more thorough cleaning would occur on a Sunday and that deep cleans would be completed as and when necessary.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff followed good practice in medicines management and did it in line with national guidance. Medicines were stored securely and were tidy and well organised. The service had appropriate protocols and policies regarding medicines. The service did not prescribe any medicines. The service had input from a local pharmacy.

Staff reviewed the effects of medication on clients’ physical health regularly and in line with NICE guidance. There was evidence within records reviewed that staff monitored and supported clients with their physical health.

Managers explained that the mandatory training for each year was available at the start of January for that year and that staff would be expected to complete the training by the end of February. The training data indicated that the service had been 100% compliant for 2025, and at the time of our inspection, in early February, 62% of staff had already completed their refresher training.