3 Kendrick Mews

On this page

• 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.

This is the first inspection for this newly registered service. This key question has been rated Good. This meant people were safe and protected from avoidable harm.

The service was safe, clean well equipped, well furnished, well maintained 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 prescribe, administer, record and store 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.

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 a clear admission and exclusion policy.

The service’s referral and admission processes ensured that all essential information about the client was received to determine if their needs could safely be met. The service followed a four-stage triage process. The admissions team were the first point of contact for referrers and assessed all referrals for suitability. The admissions team clinical co-ordinator reviewed the referral as the second stage of the triage, followed by the nursing and medical assessments as the last stages of the assessment. The service had admitted 118 clients to the service between January and July 2026.

Managers kept a list of referrals that were rejected by the service and other services they were referred to that could meet their needs.

Staff involved all the necessary healthcare services to ensure clients had continuity of safe care, both within the service and post-discharge. Staff ensured that clients with an eating disorder could access a dietician within the service.

The provider had protocols outlining the treatments offered and their pathways or protocols for risk escalation. Staff followed the provider’s escalation policy when required. The provider also had guidance for staff on discharging patients, missed appointments or unexpected exits from treatment.

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 a clear admission and exclusion policy.

The service’s referral and admission processes ensured that all essential information about the client was received to determine if their needs could safely be met. The service followed a four-stage triage process. The admissions team were the first point of contact for referrers and assessed all referrals for suitability. The admissions team clinical co-ordinator reviewed the referral as the second stage of the triage, followed by the nursing and medical assessments as the last stages of the assessment. The service had admitted 118 clients to the service between January and July 2026.

Managers kept a list of referrals that were rejected by the service and other services they were referred to that could meet their needs.

Staff involved all the necessary healthcare services to ensure clients had continuity of safe care, both within the service and post-discharge. Staff ensured that clients with an eating disorder could access a dietician within the service.

The provider had protocols outlining the treatments offered and their pathways or protocols for risk escalation. Staff followed the provider’s escalation policy when required. The provider also had guidance for staff on discharging patients, missed appointments or unexpected exits from treatment.

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 knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.

Staff were trained in safeguarding adults and children and knew how to make a safeguarding alert and did that when appropriate. Of the staff group, 99% had completed their level 3 safeguarding adults and children training. One staff member was enrolled to complete their training. The service had a dedicated safeguarding lead, which other staff could approach for advice.

Staff had reported 1 safeguarding concern in the last 12 months. Staff discussed this safeguarding incident and how they had worked with the local agencies to protect clients from harm. Staff gave examples of how they had escalated safeguarding concerns to the local authority when required.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff followed safe procedures for children visiting the service.

Mental capacity Act

100% of staff had had training in the Mental Capacity Act. The provider had a policy on the Mental Capacity Act. Staff were aware of the policy and had access to it.

Staff knew where to get advice from within the provider regarding the Mental Capacity Act.

Staff took all practical steps to enable patients to make their own decisions.

For clients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately in their records. They did this on a decision-specific basis with regard to significant decisions. Staff understood that people could have temporarily impaired mental capacity when admitted to the service, if they were intoxicated, so information was repeated the next day.

Staff ensured that clients could access the local advocacy service.

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. 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 5 risk assessments and risk management plans during the assessment. Staff used a recognised risk assessment tool which included areas of potential risks such as overdose or self-harm. Staff demonstrated a good understanding of the risks associated with mental health and substance misuse, such as self-harm, suicidal ideation and the risks to physical health. Staff reviewed client risk in their daily handover meeting.

Due to the nature of the service, they did not accept anyone that was high risk in terms of suicidal ideation. We saw evidence that staff had escalated risks appropriately where a client’s risk had increased during their stay and managed this appropriately.

Feedback and records showed that staff involved patients in their care planning and risk management plans. Clients also had daily one to one meetings with a therapist to review their progress.

Staff provided clients with information about any potential risks with the detoxification process and how to keep themselves safe. Clients described being involved in their care, including options of medicines.

Clients consented to having a level of observations from staff whilst they were going through the detoxification process to keep them safe. The service also had a detoxification room for client’s that were of a higher risk to be closely monitored by staff.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff did regular checks of the environment and identified and escalated risks to the Health and Safety and Compliance Lead, who had oversight of all health and safety related issues in the service.

The Health and Safety and compliance lead completed health and safety audits within the service. This included oversight of environmental, legionella and fire risk assessments, which were completed regularly. At the time of our visit, the service had completed 100% of their health and safety audits.

The provider had carried out a fire risk assessment in August 2025. All identified actions in the fire risk assessment had been completed, such as an addition of a new fire alarm system. The fire alarm system was tested weekly.

Personal Emergency Evacuation Plan (PEEP) forms were completed for each client, where required. For example, a plan was present for a client undergoing detoxification. A personal emergency evacuation plan is an 'escape plan' for individuals who may not be able to reach a place of safety unaided or within a satisfactory period of time in the event of any emergency. The service had a wall alarm system fitted in all client bedrooms. This meant clients and staff could use an alarm to request assistance if needed.

The clinic room was located in No 11 and was located on the second floor. Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. We had identified at the last inspection that there was no system in place for staff to raise an alarm from within the clinic room in an emergency. The provider has since addressed this, and there was now an alarm in the clinic room. The provider had action plans in place to renovate the clinic room.

Staff assessed each client to see if they were suitable to be managed in this environment, due to the ligatures present in the environment. If their risks were assessed as too high, they would not be admitted to the service and were signposted to services that could better meet their needs. Ligature cutters were stored in the clinic room and staff knew where they were, so they could locate them quickly in an emergency.

Clients had access to ensuite bedrooms, and some bedrooms had shared bathrooms. The provider told us that they would separate male and female areas where they could and ensured that clients of the same sex used a shared bathroom. At the time of our visit, there was a male and female client in separate areas with ensuite bedrooms and the service had introduced a new policy on managing sexual safety in the service.

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 service had enough staff to meet the needs of the client group and could manage unforeseen shortages in staff. The service rarely used bank and agency staff, however, they could be deployed to cover sickness and leave. As of July 2026, there were no vacancies in the service.

The service had a low staff sickness rate.

A qualified nurse was always present in the service to ensure that clients could be safely monitored and detoxed. The staff team consisted of a registered manager, registered nurses, healthcare assistants, therapy staff, housekeeping and a chef.

There was adequate medical cover during the day, and staff could escalate immediate concerns to emergency services when required for out of hour urgent concerns. Medical cover for the service was contracted through a local GP practice. In addition, a consultant psychiatrist attended the service one day each week. Both doctors had worked in the service and in the field for many years and the consultant psychiatrist was on the specialist medical register to practice in Substance Misuse Psychiatry services.

Staffing levels allowed clients to have daily one-to-one meetings with a qualified therapist, which was part of their treatment programme. Staff shortages rarely resulted in staff cancelling therapy sessions or activities.

Staff had received and were up to date with appropriate mandatory training. Staff had completed 98% of their mandatory training and had been booked on to receive their remaining training. Training included safe administration of medicines, risk assessment and mental capacity, infection control, fire safety, risk assessments, care planning, basic and immediate life support and safeguarding adults and children. Agency staff could not work in the service if they were not up to date with their mandatory training and if they did not have the experience and skills to work in substance misuse services.

Staff were experienced and qualified and had the right skills and knowledge to meet the needs of the client group. Managers ensured that staff received the necessary specialist training for their roles. Therapy staff had or were working towards a level 4 in counselling with a specialism in substance misuse services. Staff received specialist training in drug awareness and harm reduction, managing challenging behaviours and learning disabilities. Staff were also provided with additional training, such as providing trauma informed care and working with sexual compulsive behaviours.

Staff recruitment practices were safe. We reviewed three records for staff who worked for the service. These records demonstrated that appropriate pre-employment checks had been carried out, including criminal records checks and references. The service had oversight of all current staff recruitment checks through a Human Resources checklist.

Managers provided new staff with an appropriate induction. Staff could not work in the service until their core competencies were signed off by the manager. Managers dealt with poor staff performance promptly and effectively.

Managers identified the learning needs of staff and provided them with opportunities to further develop their skills and knowledge. Staff were currently training or had completed training on the new repetitive transcranial magnetic stimulation (rTMS) machine. This is a non-invasive brain stimulation therapy that uses repeated magnetic pulses to modulate neural activity and treat conditions like depression.

Managers provided staff with regular monthly clinical and managerial supervision meetings to discuss case management, to reflect on and learn from practice, and for personal support and professional development. Staff also received an annual appraisal of their work performance. As of July 2026, the percentage of staff that received regular supervision was 100% and the percentage of staff that had had an appraisal in the last 12 months was 100%.

Managers ensured that staff had access to regular team meetings. Nurses and Health care assistants attended a monthly team meeting. Minutes of these meetings were recorded and managers sent out to all of the staff team. The service also held weekly management compliance meetings and quarterly governance meetings.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

All areas were visibly clean, comfortable and well-maintained. Staff adhered to infection control principles, including handwashing and wearing personal protective equipment such as disposable gloves when carrying out specific interventions.

There were appropriate arrangements for clinical waste disposal, including sharps bins in the clinic rooms which were dated on opening and not overfilled.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date. Cleaning records were up to date and demonstrated that all areas were cleaned regularly, including the clinic room and kitchens.

Two chefs in the service were responsible for preparing and cooking the meals for the clients. They had completed level 3 food safety and level 2 food allergy training. All staff had completed 99% of their food hygiene training.

Staff followed good practice in medicines management (that is prescribing, training, detoxification, storage, dispensing, recording and emergency medicines) and did it in line with national guidance.

There were appropriate arrangements for the safe management, use and oversight of medicines and controlled drugs. The service had a contract with an external pharmacy company. A pharmacist from this company carried out a monthly medicines audit and sent this to the service manager monthly. The service had a controlled drugs accountable officer (CDAO). The CDAO is responsible for managing all aspects of controlled drugs in the service. Staff received regular drug safety updates about medicines in their monthly team meeting.

We reviewed both clients’ prescriptions and medicines administration records (MAR) and saw that clients were given their medicines as prescribed. Medicine charts also had additional information such as allergies, as well as evidence of appropriate medicine reviews.

Staff reviewed each patient’s medicines regularly and provided advice to patients and carers about their medicines. This was clearly documented in their care plans. Clients told us that they were given clear information about their medicines.

The service required the client’s medical history before commencing any treatment. The GP within the service reviewed each client before commencing any medicines. Staff reviewed each client’s medicines regularly and provided advice to clients and carers about their medicines. This was clearly documented in their records. Clients told us that they were given information about their medicines, and this was explained clearly. Medicines were prescribed by the GP or the consultant psychiatrist.

Staff reviewed the effects of medicine on clients’ physical health regularly and in line with National Institute of Health and Care Excellence (NICE) guidance. Staff provided regular physical health checks such as a blood glucose checks and blood tests, when required. Where clients were assessed as requiring alcohol detoxification when commencing their treatment programme, this was provided in accordance with NICE.