During an assessment of Residential substance misuse services
We assessed Birchwood @ Kaleidoscope House on the 12 and 13 November 2025. This is the first inspection of this service since it was registered with CQC in May 2023.
Birchwood @ Kaleidoscope House provides detoxification and rehabilitation programmes for substance misuse including drugs and alcohol. The service is for men and women aged 18 and over. The service also works with pregnant women.
The service has two wards: Acorn is a 13-bed detox ward, and Oak is a 12-bed rehabilitation ward. The service is provided in a large renovated building, set in over 9 acres of land in a rural location.
The service provided safe care and had enough staff to deliver care for clients. Staff completed risk assessments of clients and updated these regularly. Clients were provided with advice and support to reduce the harm from substance misuse. There were systems and processes to protect clients from abuse and neglect. The building was clean, well-maintained and fit for purpose. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.
Care and treatment was delivered in line with national guidance and best practice. Staff completed a comprehensive assessment of clients’ needs. Clients had access to a range of staff and support to help meet their needs. Staff received training, supervision, and appraisals.
Staff treated clients with kindness, empathy and compassion and respected their privacy and dignity. Clients had choice and control over their treatment and support. Staff worked well with other organisations to promote the best outcomes for their clients, and to ensure they got the support they needed. Support was available for staff to ensure their safety and wellbeing.
Staff delivered person-centred care and involved clients in decisions about their care and treatment. Clients and staff were aware of how to raise concerns or make a complaint.
Managers were experienced and had a good understanding of the service. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. The provider monitored and managed the service effectively. Staff went beyond the service to raise awareness, promote best practice and innovation, and share information and learning.
Mental Capacity Act Compliance Summary
Staff had had training in the Mental Capacity Act. Staff took all practical steps to enable clients to make their own decisions. For clients who might have impaired mental capacity, staff assessed and recorded their capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. Staff were aware that clients may have fluctuating capacity, particularly if they were under the influence of or detoxing from substances.
The provider had a policy on the Mental Capacity Act, which included the Deprivation of Liberty Safeguards (DoLS). 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. There had been no clients subject to DoLS in the last 12 months. The service had worked with people subject to DoLS, and had a process for assessing people and ensuring their needs could be met within an appropriate legal framework.