The Care Quality Commission
  • Residential substance misuse service

Liberty House Clinic Limited

Overall: Good read more about inspection ratings

220 Old Bedford Road, Luton, Bedfordshire, LU2 7HP (01582) 957926

Provided and run by:
Liberty House Clinic Limited

All Inspections

During an assessment of Residential substance misuse services

Liberty House Clinic registered with Care Quality Commission in February 2016 to provide accommodation for people who require treatment for substance misuse. Liberty House Clinic is a 20-bed residential drug and alcohol detoxification and rehabilitation service based in Luton. This service provides care and treatment for male and female clients. Liberty House provides medically monitored detoxification and evidence-based treatments, including 12- step treatment and dialectical-behavioural therapy (DBT).

This inspection was unannounced on 21 August 2025 and was prompted to follow up on an action plan from the previous inspection, where there was a breach of safe care and treatment. At the time of inspection there was a registered manager in post.

We rated the service as good overall, however we found a breach in relation to safe care and treatment. There was not a robust inclusion or exclusion criteria in place that clearly identified when a person’s risk was too high for the service to safely manage. People did not have a face to face appointment with a prescriber on admission and did not see a clinician throughout their treatment.

The environment was not always safe. Staff did not know where to locate ligature cutters in an emergency. All naloxone was past expiry date and was not easy to access in an emergency. Medications were not disposed of in a timely manner. There were no alarms in the building for emergencies or in the event of an incident. Some appliances in the facility were not working. Male and female bedroom and bathroom areas were mixed and not segregated, although shared bedrooms were single sex. Systems, pathways and transitions were not always safe. Most care records had a medical summary from the GP, however in some cases people had declined consent for their GP to be contacted. We did not see rating scales, such as alcohol use disorder identification test (AUDIT) or severity of dependency scale questionnaire (SADQ) being used. Medicines were not always disposed of in a timely manner. There were controlled drugs in the controlled drugs cupboard that had not been disposed of. Admission criteria was not specific. It was not clear from policies if people at high risk of withdrawal would be accepted for treatment.

However, following our inspection the provider ensured that ligature cutters and naloxone were easily accessible in an emergency. Staff used clinical institute of withdrawal of alcohol (CIWA-Ar) to monitor alcohol withdrawal. Most staff were up to date with mandatory training and received regular supervision and appraisals. Risk management plans were personalised. The provider put plans in place for safe disposal of medicines with a local pharmacy. There were regular checks to ensure that people were receiving prescribed medicines. Staff had good knowledge of safeguarding and were aware of the safeguarding process. Broken appliances were quickly replaced. The team at Liberty House worked cohesively and staff spoke positively about working at the service.

During an assessment of the hospital overall

Liberty House provides accommodation for people who require treatment for substance misuse. This assessment looked at residential substance misuse services, which we rated as good. We assessed Liberty House on 21 August 2025 to review the progress made following inspection in February 2024, where there was a breach under safe care and treatment, relating to proper and safe management of medicines. We found the service had made some improvements following our last inspection.

At this assessment we found a breach in relation to safe care and treatment. Admission to the service was not always safe. There was not a robust inclusion or exclusion criteria in place that clearly identified when a person’s risk was too high for the service to safely manage. People did not have a face to face appointment with a prescriber on admission and did not see a clinician throughout their treatment.

The environment was not always safe. Staff did not know where to locate ligature cutters in an emergency. All naloxone was past its expiry date and was not easy to access in an emergency. Medicines were not disposed of in a timely manner. There were no alarms in the building for emergencies or in the event of an incident. Some appliances in the facility were not working. Male and female bedroom and bathroom areas were mixed and not segregated, although shared bedrooms were single sex. Systems, pathways and transitions were not always safe. Most care records had a medical summary from the GP, however in some cases people had declined consent for their GP to be contacted. We did not see rating scales, such as alcohol use disorder identification test (AUDIT) or severity of dependency scale questionnaire (SADQ) being used. Medicines were not always disposed of in a timely manner. There were controlled drugs in the controlled drugs cupboard that had not been disposed of. Admission and exclusion criteria was not specific in level of risk that would be accepted into the service.

However, following our inspection the provider ensured that ligature cutters and naloxone were easily accessible in an emergency. Staff used clinical institute of withdrawal of alcohol (CIWA-Ar) to monitor alcohol withdrawal. Most staff were up to date with mandatory training and received regular supervision and appraisals. Risk management plans were personalised. The provider put plans in place for safe disposal of medicines with a local pharmacy. There were regular checks to ensure that people were receiving prescribed medicines. Staff had good knowledge of safeguarding and were aware of safeguarding processes. Broken appliances were quickly replaced. The team at Liberty House worked cohesively and staff spoke positively about working at the service.

During an assessment of Residential substance misuse services

Date of assessment: 28 February to 21 March 2024. Liberty House Clinic Limited is a residential substance misuse service provided by UK Addiction Treatment Centres (UKAT). Liberty House Clinic Limited is registered to provide residential alcohol and drug detoxification and/or rehabilitation to adults over 18 years of age. At the time of assessment, the service could accommodate 20 service users over 3 floors. We conducted our onsite assessment on 28 February 2024. We assessed a small number of quality statements from safe, effective, caring, responsive and well led key questions and found areas of good practice and areas of concern. The scores for these areas have been combined with scores based on the key question ratings from the last inspection. Though the assessment of these five quality statements indicated some areas of concern since the last inspection, our overall rating is good. We found one breach of regulations relating to medicines. We have asked the provider for an action plan in response to our concerns.

The service had incident reporting processes, staff received the relevant training for their role. Staff delivered treatment following national guidance. Staff were kind and caring. People could access the service when they needed it and were encouraged to give feedback on the service. Leaders had good oversight of service performance. However, medicines were not well managed, staff did not always follow safeguarding procedures, the environment did not meet people's needs, risk assessments and care plans did not always identify people's individual risks or needs, learning from incidents was not always robust, and governance processes did not always provide good oversight of the service.

During an assessment of the hospital overall

Date of assessment: 28 February to 21 March 2024. Liberty House Clinic Limited is a residential substance misuse service provided by UK Addiction Treatment Centres (UKAT). Liberty House Clinic Limited is registered to provide residential alcohol and drug detoxification and/or rehabilitation to adults over 18 years of age. At the time of assessment, the service could accommodate 20 service users over 3 floors. We conducted our onsite assessment on 28 February 2024. We assessed a small number of quality statements from safe, effective, caring, responsive and well led key questions and found areas of good practice and areas of concern. The scores for these areas have been combined with scores based on the key question ratings from the last inspection. Though the assessment of these five quality statements indicated some areas of concern since the last inspection, our overall rating is good. We found one breach of regulations relating to medicines. We have asked the provider for an action plan in response to our concerns. The service had incident reporting processes, staff received the relevant training for their role. Staff delivered treatment following national guidance. Staff were kind and caring. People could access the service when they needed it and were encouraged to give feedback on the service. Leaders had good oversight of service performance. However, medicines were not well managed, staff did not always follow safeguarding procedures, the environment did not meet people's needs, risk assessments and care plans did not always identify people's individual risks or needs, learning from incidents was not always robust, and governance processes did not always provide good oversight of the service.

16 April 2019

During a routine inspection

We rated Liberty House clinic as outstanding because:

  • Staff took a truly holistic approach to assessing, planning and delivering care and treatment to people who used the service. Staff reviewed, and updated care plans regularly and looked at each individual’s strengths. Clients had access to their care plans and care plans reflected their own words. Staff supported clients with issues relating to their substance misuse, including developing specific pathways for people to access support with blood borne virus testing, sexual health screening and education around such topics. The range of treatment options included those recommended by national guidance and the 12-step approach. Managers and staff focused on ways in which safety and outcomes for clients could be improved, including the use of a capacity and intoxification test when people began treatment.
  • The continuing development of staff skills, competence and knowledge were recognised as being integral to ensuring high quality care. Staff were proactively supported to acquire new skills and share best practice. All staff had completed their mandatory training, received regular supervision and had received an annual appraisal.
  • Feedback from people who used the service and those who were close to them was continually positive about the way staff treated people. People said that staff went the extra mile and the care they received exceeded their expectations. Clients felt empowered in their treatment. Clients told us their treatment was individualised, and that staff listened to their choices. We observed staff interacting with clients and family members in a respectful, kind and supportive manner.
  • Managers had an inspiring shared purpose and motivated staff to succeed. Members of the senior management team were visible within the service, the service manager had clear direction to further improve treatment and client experience at Liberty House Clinic. Staff felt positive and passionate about their roles and the client group they were supporting. Staff felt valued, positive and proud about working for Liberty House Clinic.
  • There were consistently high levels of constructive engagement with staff. Staff had access to team meetings, additional ‘flash’ meetings to discuss any issues requiring immediate attention, such as medication errors and carried out weekly, monthly and quarterly internal and external audits, which covered all aspects of service provision.
  • The service had recently implemented a new easy to use electronic case management system which had been specifically developed for addiction treatment facilities and could be customised to suit the individual service.
  • Staff completed medication management to a high standard. Physical health checks were completed prior to initiating treatment and detoxification and throughout treatment.
  • Staff referred clients who had successfully completed treatment to become part of the alumini. UKAT organised recovery events for the alumini group to keep the recovery momentum ongoing after treatment. Clients who had completed treatment were supported at their local UKAT centre for a year following treatment, family members also had the opportunity to receive support for a year following treatment.

16 to 17 May 2018

During a routine inspection

We do not currently rate independent standalone substance misuse services.

We found the following areas of good practice:

• Staff had access to radios and mobile phones during 1:1 and group sessions, meaning they could contact other staff for support during an emergency if required. Staff gave clients who were detoxing from substances a radio to contact staff.

• The service had recently been decorated; furnishings were clean and well maintained. All communal areas were clean and in good order. The clinic room was clean and tidy.

• Overall, 100% of staff had completed mandatory training.

• All clients had a risk assessment and a risk management plan.

• Medical assessments completed by the medical team were comprehensive, there was a clear medicines management process in place, all medication was stored appropriately. Physical health checks were completed by the medical team before initiating a treatment and detoxification plan. Staff completing blood pressure checks, breathalysing, and urine drug testing were fully trained.

• The service reported incidents effectively, and learning from incidents was shared through various meetings.

• Care plans were personalised, recovery orientated, holistic and looked at strength areas for each client.

• Clients had access to a range of therapeutic groups and activities to support treatment.

• All staff, including bank staff had received a thorough induction, were regularly supervised and all eligible staff had an appraisal.

• Clients we spoke with told us staff were helpful, caring, approachable and they felt safe using the service.

• Family members received support and learnt how to offer encouragement to their loved one on discharge through attending weekly family groups.

• Clients formulated their own discharge plans which included arrangements for unplanned exit from the service. On occasions where a client would want to disengage from treatment, the service would ensure that the client was able to get home safely and the client’s family would be informed.

• The service held weekly community meetings where clients were encouraged to raise any issues with staff.

• Staff morale at the service was high. Staff told us that they felt valued and rewarded within their roles; staff said they all worked well together as a team.

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

• Some clients we spoke with felt they could have been more involved with their care plan.

04 January 2017

During a routine inspection

We do not currently rate independent standalone substance misuse services.

We found the following issues that the service provider needs to improve:

  • Staff did not have access to personal alarms for staff and client safety. There were no alarms located throughout the building.

  • The service did not have designated bathrooms for males and females. The service had a shower room on the second floor which contained three showers, there was no frosting on the shower doors to maintain client dignity and privacy.

  • Female and male sleeping areas were not segregated. Risk assessments did not include risk of mixed sex accommodation and were not being regularly updated.

  • The blood pressure machine and alcometer ( had not been calibrated. Staff had not received adequate training on taking clients blood pressure.

  • Staff did not record the temperature of the clinic room. Staff did not know if the room temperature was too high.

  • Staff were not reviewing or updating care plans regularly. Staff completed risk assessments as part of the initial assessment but risk assessments were not reviewed or updated regularly or following an incident.

  • The service used several folders for recording different types of incident, including serious incidents, incidents, medication errors and safeguarding. This created confusion for staff as incidents may have fallen in to more than one of the recording categories. Staff were not able to feedback any learning from incidents.

  • Clients had a lack of one-to-one key working and activities outside of therapy. Clients told us the only physical activity they were able to take part in was a walk around the local park with a staff member.

  • Staff were not being supervised regularly in line with the provider’s supervision policy.

  • Historically management did not follow the service recruitment policy. The new management team had developed a system to ensure that staff recruitment followed the provider’s policy.

However, we also found the following areas of good practice:

  • A recently implemented management team had ensured that all staff had completed mandatory training. Staff morale at the service had recently improved and staff felt able to input to service development.

  • We saw policies, procedures and training related to medication and medicines management including prescribing, detoxification, and assessing clients’ tolerance to medication. We observed medication administration which was in line with NICE guidelines.

  • On admission clients had a doctor’s assessment with a member of the clinical team. We saw record of thorough clinical assessments and prescriptions located within client care and treatment files.

  • Prior to discharge all clients completed an exit survey which included plans and coping strategies following discharge, improvements in mental and physical health and feedback on the treatment they received.

  • We observed staff interacting with clients in a kind, considerate and caring manner.Clients we spoke with told us staff were interested in their wellbeing and that staff were respectful, polite and compassionate. Clients felt safe

  • All clients we spoke with were aware of the service complaints procedure. The service held weekly community meetings where clients were encouraged to raise any issues with staff.