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Archived: Charterhouse Clinic Requires improvement


Inspection carried out on 08 & 15 January 2019

During a routine inspection

We rated Charterhouse Clinic as Requires Improvement because:

  • The service did not robustly manage the risks associated with detoxification from drugs and alcohol. Staff did not regularly review client’s physical health observations during detoxification in line with national guidance. The provider did not use dependency scales on admission or consistently use withdrawal scales such as the opioid withdrawal scale to monitor the severity of the client’s withdrawal symptoms in line with national guidance.
  • Governance systems were not robust. The service did not have a system to monitor areas for improvement identified through self-auditing and leaders did not maintain a robust risk register.
  • Staff did not robustly mitigate the risks associated with mix gender accommodation by conducting risk assessments.
  • The service did not hold regular staff team meetings. The last team meeting was held in August 2018.
  • The training matrix was not up to date and did not accurately reflect the dates staff had completed their annual training.


  • Staff spoken with, reported good team morale and said they were proud to work for the provider.
  • Staff provided a range of psychological therapies recommended by The National Institute for Health and Care Excellence. These included cognitive behavioural therapy and group therapy. Some of the topics covered in group therapy were mindfulness, meditation, reflection and relapse prevention.
  • The provider had a whistle blowing policy in place. Staff were aware of the policy and told us they were confident in raising a whistle blowing.
  • We observed staff interacting with clients in a kind and respectful manner throughout the inspection.
  • Clients told us they felt safe whilst in treatment and that staff were kind and caring. All clients had a named key worker who met with their client weekly.
  • We saw evidence that clients were involved in developing and setting their own care plan and goals.

Inspection carried out on 05 February 2018

During a routine inspection

We do not currently rate independent standalone substance misuse services.

We found the following areas of good practice:

  • Environmental risk assessments were completed and up to date and there was a ligature risk audit in place which provided adequate mitigation. The provider had undertaken internal building works to fill in open beams which had previously been identified as ligature risks.

  • We reviewed five care records. All clients had a pre admission assessment and an up to date risk assessment. All risk assessments were detailed and records contained a plan for unexpected exit from treatment.

  • Staff provided a holistic, bespoke service and treatment plans were written to support all areas of the client’s life. Staff encouraged clients to establish links with support services in the community. Prior to discharge staff made referrals to services which were local to the clients home area.

  • All of the staff responsible for the administration of medication had received medication management training. The psychiatrist followed National Institute for Health and Care Excellence guidelines in prescribing and reviewing medication.

  • All of the clients that we spoke with told us staff were compassionate, kind and supportive and they felt very safe within the service.

  • The doctor attended the service on the day of admission and weekly thereafter. There were additional skype meetings and telephone calls as required.

  • There was access to groups throughout the day and during the evenings on week days, and there were activities and some groups held at the weekend

  • An aftercare group was provided for clients who had completed their treatment and they could also phone for support.

  • There was an up to date risk register and the manager accessed this to submit and update risks. Environmental risk assessments, including ligature risk audits had been introduced and were up to date.

  • The service used key performance indicators to measure performance against a range of objectives. These included food standards, room standards, staff numbers and medication audits.

  • Staff knew where to access the whistle blowing policy and how to use it. There had been no whistle blowing cases in the last twelve months prior to inspection. Staff told us that they enjoyed working at the service and that morale was high.

However, we also found the following issues that the service provider needs to improve:

  • The sharps bin was stored in the clinic room and was full at the time of inspection.

Inspection carried out on 12 July to 13 July 2016

During a routine inspection

We do not currently rate independent standalone substance misuse services.

We found the following areas of good practice:

  • There were enough skilled and experienced staff on duty at all times. Charterhouse clinic did not use bank and agency staff. All staff had received full and comprehensive induction, role specific training including medications management, and equality, and diversity awareness training. Addressing staffs’ emotional and physical wellbeing were a priority for the provider. There were robust individual and group supervision arrangements in place, which all staff accessed.

  • All staff were trained in the Mental Capacity Act 2005 (MCA), and Deprivation of Liberty Safeguards (DoLS). All staff understood their responsibilities in relation to the MCA and DoLS. The provider had accessible policies relating to MCA. The provider had not made any DoLS applications in the twelve months prior to inspection. The provider dealt with safeguarding issues in a timely manner. Staff had completed training in safeguarding adults and children and understood what constituted a safeguarding concern, and how to report it.

  • Between May 2015 and April 2016, the provider had investigated one serious incident and sent two notifications to CQC. They had shared the learning with staff and clients, and made changes to their service accordingly. The provider was compliant with the duty of candour requirements.

  • All clients had robust and up to date risk assessments. They were personalised, holistic, and included positive risk taking management plans, using least restrictive practice. All care records had signed consent to treatment forms. The provider had effective protocols in place to manage client transfers including unexpected exit from treatment.

  • The provider had clear admission and discharge policies. They had clear response times for acceptance of referral, initial assessment, admission, and post admission assessment. They were able to see urgent referrals. The provider explained funding options and arrangements to clients before they accepted a place at Charterhouse clinic. All clients had a named key worker, matched to them based on skills and experience. We saw an effective daily handover where staff discussed all clients’ health and psychological needs, along with work allocation for the day.

  • Treatments included individual and group therapy, cognitive behaviour therapy, motivational interviewing, assignment and goal setting work. Clients received clear information about the clinical team, treatments they could expect to receive, and treatment options. Clients were encouraged to use external support groups such as Alcoholics Anonymous (AA) and Specific Measurable Assignable Realistic Timely (SMART) recovery.

  • All clients had information about the side effects of detoxification and the medications used, staff knew what side effects to look for and how to address them. New admissions for detoxification received comprehensive physical and psychological health screening and assessment. After which, clients commenced an initial medication regime with immediate effect.

  • The consultant psychiatrist used remote treatment practice in line with the general medical council’s guidance (GMC) on remote treatment practice, including on line video consultation known as Skype, when he could not be with the client face to face. Remote consultations were followed up with face-to-face meetings within two days. The provider followed National Institute for Health and Care Excellence guidelines relating to detoxification and medication to inform their practice.

  • The organisation had a clear vision and set of values that staff and clients understood and supported. The organisation valued its staff and encouraged both personal and professional development. All staff had clearly defined job descriptions, and recruitment processes were robust. Staff had objectives focussed on service development, improvement and learning. Leadership was effective and encouraged an open, honest, and supportive culture. Clinical team leads provided leadership, training, and supervision for the wider team. Job satisfaction and team morale was high. Staff told us they were proud of the culture they helped create, and the quality of the service they provided.

  • The organisation encouraged creativity, innovation, and learning from other substance misuse services both nationally and across Europe. The provider encouraged staff to become involved in research and the consultant psychiatrist was a member of the Society for the Study of Addiction.

However, we also found the following issues that the service provider needs to improve:

  • There was no fridge in the clinic. Staff kept medications requiring refrigeration in an unlocked fridge in the main office.

  • The provider did not have any advocacy arrangements in place.

  • Clients risk assessments did not reflect how identified environmental risks were to be mitigated.

  • Local governance arrangements were in the developmental stage, including the risk register. Policies, procedures and protocols were being reviewed and improved, but as yet did not include an equality impact assessment.