3 Kendrick Mews

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first inspection for this newly registered service. This key question has been rated Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes operated effectively within the service. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected and analysed data about outcomes and performance. They used this to identify improvements.

We have not awarded this service a score for Well-led.

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

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff could explain how they were working to deliver high-quality care. One staff member commented on the positive culture within the service that supported a learning environment.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. The service had ensured that staff were involved in the creation of new unauthorised leave policy.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. Leaders had a good understanding of the service they managed. They could explain clearly how the team was working together to provide high-quality care.

Leaders were visible in the service and approachable for clients and staff. Staff could also contact them by telephone.

Leadership development opportunities were available, including opportunities for staff. Staff development was supported through access to further training and courses. Staff reported that the provider offered opportunities for ongoing learning and professional development. For example, nurses within the service had received phlebotomy training and could take client's bloods when required.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff we spoke with told us they felt comfortable to raise concerns with managers and that their voices would be heard. The provider had a whistleblowing policy. This explained steps for staff to take if they had a concern and actions that would be taken.

Clients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Feedback could be provided in the daily planning meeting and in the weekly community meetings.

Staff enabled clients to give feedback regarding the service they received. The service asked clients to complete an exit survey upon their discharge from the service to obtain feedback about the service and their experience. The service received positive feedback from clients that had used the service between January and July 2026.

Managers collated feedback to identify and trends or themes that were doing well and where other areas could be improved. Feedback data showed that 94% of clients would recommend the service to others for substance misuse treatment and food, housekeeping and the premises all scored very well.

Managers had access to the feedback from clients, carers and staff and used it to make improvements. Managers identified through the client feedback survey that there were certain areas that could be further improved, such as maintenance issues and storage issues.

Staff had access to the feedback from clients, carers and staff and used it to make improvements to the service. From the recent client survey, staff had identified several areas that needed improving. This included better support post-diagnosis and clearer communication about medicines.

There was evidence that changes had been made as a result of client feedback. For example, one client had fed back that they would like an orientation and tour of the service once they had stopped feeling the effects of alcohol or substances, as they could not remember this when they were intoxicated. The service then ensured that a full orientation to the service was provided the next day after the client had settled in.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The service had an equality and diversity policy and outlined what was expected of staff in promoting equality, respecting diversity and preventing discrimination or harassment in any form.

Staff could apply to work flexibly, depending on their role in the service. Staff could use a hybrid working model by working from home and on-site.

The service employed a diverse team of staff to ensure it is diverse in its make-up and representative of the client group.

Employment practices promoted equality of opportunity. Managers said the service did not discriminate against staff from minority groups. Staff did not raise any concerns about discrimination and all the staff we spoke with said they were treated fairly. Some members of the staff team had lived experience of substance misuse and were representative of people in treatment.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Since our previous inspection of this service, leaders had strengthened the service and further embedded governance processes to ensure the ongoing safety and quality of the service.

The service had an assurance framework in place. This clearly identified how key information relating to quality, safety and improvement would be assessed and shared with all staff in the service. The framework identified what must be discussed at staff team, governance and management meetings to ensure that essential information, such as, risk, learning from incidents, safe environments, safeguarding and complaints, was shared, discussed and implemented.

Staff had implemented recommendations from incidents, complaints, changes to policies and safeguarding alerts at the service level. These were discussed at the quarterly governance meetings, weekly management meetings and monthly staff meetings. Incidents and safeguarding concerns were also discussed in the daily staff handover meetings as well as client assessments and emerging risks.

Staff completed audits to provide assurance on the performance of the service. Staff acted on the results. Managers had oversight of the audits on a dashboard to ensure that certain areas were compliant, such as health and safety audits, clinical audits, therapeutic audits, record keeping and governance. Audit compliance rates were recorded monthly and reviewed in detail in the quarterly governance meetings. The service used systems to collect data that were not over-burdensome for frontline staff.

Managers ensured that learning from incidents, complaints and safeguarding concerns were shared with the other service managers under the same provider who attended the weekly compliance meetings and the quarterly governance meetings.

The service maintained a risk register, which was reviewed in the quarterly governance meetings. Staff concerns matched those on the risk register. Risks included environmental ligature risks, data protection and fire and health and safety. The service also had plans for emergencies.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to deliver high quality care.

Information governance systems included confidentiality of patient records. Information was kept electronically and in one format.

The manager had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. For example, HR records, supervision records, staff training data and audits. Information was in an accessible format, and was timely, accurate and identified areas for improvement.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the clients. Clients could be escalated to an acute inpatient substance misuse service under the same provider if clients required a higher level of support.

The service worked closely with the other services under the same provider and held joint weekly management meetings and quarterly governance meetings to share good practice and changes to the service. For example, the services had recently worked together to produce a joint policy on managing sexual safety within the service.

The service worked well with other agencies including health and social care professionals, community mental health teams and the local authority safeguarding team.

Clients could meet with members of the provider’s senior leadership team to give feedback. We saw evidence that staff felt comfortable providing feedback and expressing their opinions.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The service showed excellent outcomes of how their service had improved the overall long-term health and recovery outcomes for clients that used the service, in addition to their detoxification. Managers had recorded that there had been 39 successful detoxes within the service within the last 6 months.

The service was also able to evidence how it effectively had improved the overall quality of life for clients that had used the service from recording their outcomes from the start and finish of the service, through a client led questionnaire. Over the last 12 months, 100% of clients that used the service said that their mental health, view of self, relationships with family and friends and their overall life had improved. 62% of clients with a mild eating disorder fed back that they had improved their relationship with food after leaving the service.

The service measured client’s anxiety using the Beck Anxiety Inventory (BAI) and depression using the Beck Depression Inventory. (BDI). Clients were asked to complete a questionnaire with scores to assess their anxiety and depression upon their admission and this was repeated on their discharge. Managers were able to evidence that within the last 12 months, 86% of client’s anxiety had improved and 91% of client’s depressive symptoms had improved since using this service.

Innovations were taking place in the service. The service had recently acquired a 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. Staff were currently being trained on how to administer this treatment. This was a recommended intervention from the National Institute for Health and Care Excellence (NICE).

A range of audits were in place, and we saw evidence where this had led to improvements in practice and learning. Managers discussed audits that were low or had declined with staff in the monthly staff meeting and any practice that could be further improved. The service had recently introduced a new data breach audit to ensure that the service could monitor data breaches and to help remind staff on how to maintain good practice when using personal data.

Managers and staff shared lessons learnt after incidents and met to discuss incidents and make improvements. For example, the service had introduced an unscheduled discharge care plan to ensure that staff and residents agreed on what the next steps were if the client unexpectedly left the service.

The registered manager kept an improvement log highlighting areas of improvement for the service, the person responsible, progress updates and completion dates. This was introduced to improve accountability and service quality and provide clear expectations for staff, ensure consistent standards across services and support data-driven improvement.

The consultant psychiatrists attended regular consultant network meetings for peer support, to discuss complex cases and share good practice.

Managers were currently introducing Intravenous therapy (IV) to offer this to clients who wished to have vitamins, medicines and fluids through a needle in a vein as this is absorbed by the bloodstream quickly.