Turning Point - Stanfield House

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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 remained Good. This meant people were safe and protected from avoidable harm.

The service was safe, well equipped, well furnished, 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 support clients with medicines. The service managed client safety incidents well.

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.

We scored the service as 3. 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 we spoke with understood safeguarding processes and there were clear systems to identify, share and act on concerns. All staff members had completed safeguarding training and could explain how concerns would be recognised, reported and escalated. They described a range of routes for raising concerns and demonstrated an understanding of their responsibilities to keep clients safe.

The service had systems to support clients to raise concerns and access support. Clients could raise concerns directly with the management team, through a 24-hour on-call telephone and text service, or via an anonymous comments box that was reviewed regularly. Concerns could also be discussed during weekday client check-ins. Posters were displayed throughout the service that promoted external sources of support.

The service had systems to help protect people from abuse, exploitation and avoidable harm. Cameras were positioned in most communal areas and recordings were reviewed following weekends and evenings to identify any incidents or concerns while staff were off-site. There were no staff on site between 8pm and 9am the following day, however, this arrangement was considered as part of the service’s pre-admission assessment. Support could be sought on an evening through the service’s on-call system. The organisation had a policy in place detailing how it made, used, and stored recordings. Clients were informed of the use of close circuit television (CCTV) and monitoring at admission, and we saw signage throughout the property highlighting its use. The service had ‘house rules’ which reduced the risk of exploitation and financial abuse. These included not lending money or tobacco to other clients and not entering another client's bedroom. These rules were agreed with clients on admission.

Visiting arrangements were managed safely and reflected client's individual needs and circumstances. Family visits were accommodated throughout the week, including visits from children and young people, which were identified during assessment and appropriately risk assessed. Clients could meet with family members in their bedrooms. We observed one bedroom that had been partially decorated to support visits from a client’s child, including games and toys. When not in use by clients, the lounge could also be used as a visitors’ room.

We scored the service as 3. 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 had robust referral processes. Staff completed pre-admission assessments and had the autonomy to make decisions about whether a referral could be safely accepted. Information gathered at referral included personal details, funding arrangements, care preferences and involvement from relevant professionals. Assessments were completed online, by telephone, or in person to explore the person's needs in more detail and determine whether the service could provide appropriate care and treatment.

Where the service did not feel it was appropriate to accept the referral, they signposted other options available in the area, utilising services offered both within and outside of Turning Point. Where appropriate, this included signposting to Alcoholics Anonymous, Narcotics Anonymous, and community or faith groups.

There was a structured discharge process in place to support people moving into the community.

We scored the service as 3. 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 we spoke with understood safeguarding processes and there were clear systems to identify, share and act on concerns. All staff members had completed safeguarding training and could explain how concerns would be recognised, reported and escalated. They described a range of routes for raising concerns and demonstrated an understanding of their responsibilities to keep clients safe.

The service had systems to support clients to raise concerns and access support. Clients could raise concerns directly with the management team, through a 24-hour on-call telephone and text service, or via an anonymous comments box that was reviewed regularly. Concerns could also be discussed during weekday client check-ins. Posters were displayed throughout the service that promoted external sources of support.

The service had systems to help protect people from abuse, exploitation and avoidable harm. Cameras were positioned in most communal areas and recordings were reviewed following weekends and evenings to identify any incidents or concerns while staff were off-site. There were no staff on site between 8pm and 9am the following day, however, this arrangement was considered as part of the service’s pre-admission assessment. Support could be sought on an evening through the service’s on-call system. The organisation had a policy in place detailing how it made, used, and stored recordings. Clients were informed of the use of close circuit television (CCTV) and monitoring at admission, and we saw signage throughout the property highlighting its use. The service had ‘house rules’ which reduced the risk of exploitation and financial abuse. These included not lending money or tobacco to other clients and not entering another client's bedroom. These rules were agreed with clients on admission.

Visiting arrangements were managed safely and reflected client's individual needs and circumstances. Family visits were accommodated throughout the week, including visits from children and young people, which were identified during assessment and appropriately risk assessed. Clients could meet with family members in their bedrooms. We observed one bedroom that had been partially decorated to support visits from a client’s child, including games and toys. When not in use by clients, the lounge could also be used as a visitors’ room.

We scored the service as 3. 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. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 10 client care plans, which included details of risk assessments and mitigation plans. All 10 client care plans were up to date and appropriate to meet the needs of clients.

Staff involved clients in care planning and risk management, ensuring information was provided in a way clients could understand and engage with. The individual client voice was evident throughout all 10 of the care plans we reviewed.

Clients could give feedback about their care in client check-in meetings, held every weekday, and through an anonymous feedback and suggestion box.

The service had a list of restricted items, including weapons, alcohol, and illicit substances. Clients were made aware of the restrictions at point of admission, and posters throughout the service provided further information. The restrictions were in line with the service’s model of care, expectations of clients whilst receiving treatment, and were proportionate to the risk presented.

Advocacy services were available and advertised throughout the service. Staff discussed advocacy with clients as part of the pre-admission assessment process, and during our inspection, we saw a client being visited by an advocate to discuss their care.

We scored the service as 2. 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.

The environment was generally clean and safely maintained. Staff conducted daily and monthly health and safety visual checks of the environment. This included a review of fire exits, emergency equipment, signage, and general cleanliness in communal areas both within and external to the property.

Managers also completed a monthly housekeeping checklist, which included access, security, equipment, asbestos and Control of Substances Hazardous to Health (COSHH) items, infection prevention and control (IPC), bathrooms, bedrooms, and food and drink areas.

However, these systems were not always effective. During the inspection we identified some environmental issues that required attention, such as a lounge radiator stored against a corridor wall pending repair. Staff were aware of these issues and identified them during an environmental walkaround, but they had not been recorded on the Health and Safety Daily Visual Form and Monthly Checklists Log, or monthly Housekeeping Checklist. Following our feedback on the first day of the inspection, the management team took prompt action and liaised with the landlord to arrange remedial works. We were satisfied that the steps taken by the management team ensured that future issues would be appropriately identified and addressed in a timely manner, and that the risk presented at the time of our inspection was quickly mitigated.

The service had a ligature risk assessment which had been completed in September 2025 and was reviewed annually. Where appropriate, staff considered risk in individual risk and suicidal ideation assessments, within client’s care plans. Other mitigations included use of window restrictors, door locks, and staff positioning. Ligature cutters were available throughout the property, with locations now clearly identified. Staff we spoke with were able to identify the whereabouts of ligature cutters.

Staff also had timely access to naloxone, an emergency medication that is used to temporarily reverse life-threatening opioid overdoses.

We scored the service as 3. 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.

The core staffing team was composed of 4 staff members, including a team leader, two recovery support workers, and an administrative assistant. There was an open vacancy for a third recovery support worker and the service were actively recruiting for this position. Former clients provided additional support, and had undergone an induction programme of training as peer support workers and volunteered their time to support others through their rehabilitation. Where necessary, managers could source support from other Turning Point services, or through the use of bank or agency staff if required.

Staff were on site between 9am and 8pm, Monday to Sunday. An on-call system was operated outside of these hours, and was available to clients, their families, and carers. Clients told us that there were enough staff to meet their needs.

Staff had completed required training, with overall completion at 97%, and the lowest completion rate for a staff member at 89%. At the time of our inspection, training was appropriate to meet the needs of the client group. Staff were trained in first aid, though physical health monitoring and medical support was provided through system partners. Staff we spoke with were confident, experienced, and knowledgeable about the care they provided.

Managers praised Turning Point’s managerial development programmes, ‘Aspire’ and ‘Inspire’, noting it as beneficial to their learning. ‘Aspire’ developed managers’ skills in day-to-day operational activities, while ‘Inspire’ focused on personal development, reflective practice, and wellbeing.

We scored the service as 2. 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.

As part of their recovery, clients maintained a rota of delegated cleaning and household tasks, which was agreed weekly. This was further supported by management housekeeping checklists and Turning Point’s ‘Safer Food, Better Business’ policy.

Overall, we found the service to be generally clean and tidy. Bedrooms were clean and well maintained. The garden area was also well maintained, and most communal areas were clean, tidy, and free of clutter. Mop heads were stored correctly, chopping boards were clearly labelled, and the service conducted regular legionella checks. Legionella is a bacteria found in fresh water and soil. It spreads when contaminated water droplets are inhaled and can lead to illnesses including Legionella’s Disease.

However, there were some areas requiring attention. The kitchen was unclean in places and some food was out of date. It was not apparent how food in the freezer was being rotated. Staff were working with clients to promote independence and independent living skills. Antibacterial hand gel in the entranceway, and nitrile gloves in the kitchen, were out of date.

When we raised these issues during the first day of inspection, the management team took immediate action including booking a deep clean of the property, replacing out of date personal protective equipment (PPE), and cleaning areas within the kitchen. A plan was made to more frequently check food storage and expiry dates, and a follow-up discussion was to be held with clients to reiterate expected standards.

We scored the service as 3. 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.

As part of the pre-admission process, the service identified medicine used by clients and any associated risks, ensuring mitigations were in place. Staff supported clients to safely self-administer their own medicine. Staff completed audits, tablet counts, urinalysis, and alcoholometer checks. The service did not prescribe medication, but worked in partnership with a local GP, who supported monitoring of ‘when required’ medicines.

Most medicine was stored in client’s individual bedrooms in a locked cabinet, and staff supported clients with the correct self-administration of prescription drugs, such as pregabalin, codeine, and zopiclone.

2 clients had small medicine fridges for storage of medicines requiring refrigeration, such as insulin or eyedrops. Clients could be provided with fridges, if necessary. Staff completed assessments with clients prior to medication being held in rooms, taking a least restrictive, risk-based approach, ensuring the client’s independence was promoted where appropriate. Clients were supported by staff and local GP services to ensure their medicines were appropriately stored and monitored, including recording fridge temperatures.

We reviewed 10 medicine records and were satisfied that the service was taking a comprehensive approach to medicine management. Emergency medicines were also checked, found to be in date and stored appropriately, allowing for timely usage if required.

The service did not conduct any physical health monitoring at the time of our inspection, as this was led by local GP services.