Liberty House Clinic Limited

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.

At our last assessment we rated this key question as requires improvement. At this assessment the rating has remained. People were not always safe and protected from avoidable harm. We found a breach of safe care and treatment due to admission criteria not being specific. For example, it was unclear if people at high risk of withdrawal from alcohol or drugs would be accepted into the service.

Procedures for managing risk of self-harm or suicide were not embedded. For example, ligature cutters were not available on request. Admission processes were not always safe. Male and female bedroom and bathroom areas were not segregated. Some appliances were broken. There were no alarms in the building for emergencies or incidents. GP medical summaries were not present in all care records if a person had not given consent. People were not seen face to face by a prescriber on admission. Medicines management processes were not embedded. All naloxone at the service had expired and there was not an embedded process in place for disposing of medications.

However, the environment was clean. There was an incident log in place, incidents were investigated and staff had good knowledge on how to report incidents. Complaints were investigated and people received a written response to their complaints. Staff were able to tell us their safeguarding procedures. Risk management plans were regularly reviewed and discharge plans were personalised. Most staff were in date with their mandatory training.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had an incident log in place, which recorded incidents such as safeguarding concerns, accidents, medication errors, violence and aggression and physical health concerns. We reviewed incident reports for medication errors and found that incidents had been appropriately investigated and there was evidence of duty of candour, where people were given an explanation when things went wrong. Duty of candour mandates health and social care providers to be open and honest with clients about their care and promotes a culture of learning.

Staff were able to tell us what incidents they would report and how to report them. For example, one staff member told us that in the event of a seizure, they would follow an emergency procedure of calling an ambulance and would complete an incident report. We reviewed the incident log and found actions taken included, following emergency procedures and calling an ambulance. Being aware of incident reporting processes meant that future incidents could be prevented and risks were mitigated.

We reviewed the service’s compliments and complaints log. We found that complaints were thoroughly investigated. Actions taken were documented and learning from incidents was identified. For example, when an incorrect complaint process was given to a person, staff members involved were reminded of correct processes. Thorough investigation of complaints meant that issues with process could be identified.

Leaders told us that learning was shared with staff through bulletins, team meetings and through supervision.

Admission procedures were not always safe. Medical summaries were not always present in care records that we reviewed. At the time of our inspection 2 out of 6 care records we reviewed did not include a GP medical summary, due to people refusing consent to share information with their GP. Department of Health drug misuse and dependence guidelines highlight the importance of regular communication and information sharing between specialist services and the client’s GP because of ‘the significant physical and psychiatric morbidity associated with drug use and complex pharmacological interactions between medications used to treat drug dependence and other medications’. The guidelines further state that ‘In exceptional circumstances, treatment may continue despite a patient having withheld consent for sharing of information with their GP.’ While a medical summary from a GP requires consent from the person before it can be obtained, communication with a GP prior to admission and at discharge is best practice. Where consent is not given for a GP medical summary to be obtained, prescribers should be assured that they can make safe clinical decisions. Doctors told us they would assess if they could safely prescribe to a person and where it was not safe, they would refuse admission. However, all people had a full assessment of their substance use on admission.

There was an admission criteria in place, which was last reviewed in March 2024 and was under review at the time of inspection. The admission criteria stated that MAPPA 3 offenders, those sectioned under the Mental Health Act and those with physical health issues that could not be managed would not be accepted into treatment at Liberty House. Admission criteria was not clear about appropriateness of the service for level of need for physical or mental health. For example, we found incidents of people having seizures at the service, meaning that some people at high risk of physical health complications were admitted. Managers told us that people needed stable mental health to be admitted to the service, however this was not stated in the admission criteria. Procedures for managing people with high risk mental health concerns were not embedded. For example, staff could not locate ligature cutters when requested. However, following our inspection ligature cutters were placed in an easily accessible location.

Prescriber appointments were completed virtually on admission and people did not have face to face appointments with a clinician throughout their treatment. Thorough physical health checks were not completed on admission. Support staff were responsible for conducting physical health checks on admission, which included blood pressure monitoring, pulse and oxygen monitoring. Managers told us staff compliance for physical health monitoring training was 96% and competencies were checked annually. Physical health monitoring is essential to ensure safe prescribing.

However, discharge policies outlined a clear process for planned and unplanned discharges from the service. This included liaison with referring agencies, family, probation and the person’s GP where appropriate. There was a medical emergency response procedure in place. This stated that paramedics should be called in a medical emergency, in the absence of a medical professional. Staff told us that people would be taken to a walk in GP surgery, 111 would be called or an ambulance would be called in an emergency.

Staff were able to recognise adults or children at risk of suffering harm or abuse and worked with other agencies to protect them. Staff we spoke with had a good knowledge of safeguarding procedures. Safeguarding procedures were followed when children were visiting the service. Staff told us that children were not able to come into the building to visit family members at Liberty House. Welfare checks were completed on children of people in treatment and safeguarding referrals were completed where necessary. Safeguarding training compliance was 100% at the time of inspection.

There was an incident log in place, which recorded any safeguarding incidents and actions that had been taken. For example, a person had disclosed past abuse to staff at Liberty House. Appropriate action was taken, and a safeguarding referral was completed.

There was a comprehensive safeguarding children policy in place, which stated types of abuse and actions that should be taken if a staff member had concerns about the welfare of a child. There was also a safeguarding vulnerable adults policy, which explained types of abuse and the role of the local authority, as well as an explanation of the Mental Capacity Act 2005.

Managers had knowledge and experience of managing safeguarding concerns, including contributing to Serious Case Reviews (SCR’s), as well as experience of safeguarding in previous roles. Managers attended monthly safeguarding meetings, where cases were reviewed and learning was discussed. This meant that managers had the experience and knowledge to ensure that people were safeguarded.

Records showed appropriate risk management plans were in place for all clients. We reviewed 6 risk assessments during our visit to Liberty House. All client records we reviewed had a risk assessment in place and risks were reviewed regularly.

We observed a handover meeting, where a multi-disciplinary team discussed people’s progress in treatment. This included the centre manager, therapists and support workers. Staff had good knowledge about each person in treatment, were able to identify risks and put plans in place to mitigate risk.

Discharge plans were individualised and were related to personal circumstances. Staff discussed the risks of early exit from treatment with people. One early discharge plan advised of the risk to health if leaving alcohol detoxification early, which could result in withdrawal. Harm reduction advice can reduce the risk of dangerous alcohol withdrawal or can make people aware of how to reduce risk if they use substances on discharge.

We did a tour of the environment and found processes in relation to ligature risk in the environment were not embedded. We requested to see ligature cutters and staff were not initially able to locate any ligature cutters. After some time, ligature cutters were found and put back in the correct location. The provider’s admission criteria stated that those sectioned under the Mental Health Act would not be admitted to the service, however it did not state self-harm or risk of suicide would be an exclusion criteria. Managers told us that a decision about a safe admission would be made by the doctor.

There was not a segregated area for male and female bedrooms. Although shared bedrooms were single gender, male and female sleeping areas were mixed. Bathrooms and toilets were also mixed gender. The service had a sexual safety policy in place, which stated the service’s rationale around having a mixed gender environment. This included a “pathway to normal living.” The provider also had mitigation in place, which included the use of closed-circuit television (CCTV) and staff walkarounds to maintain safety of people using the service. During our review of incidents we found there had been an incident relating to sexual safety. The service took appropriate steps following this incident and a person was discharged from the service.

Some appliances were not well maintained. There was a broken dishwasher in the communal kitchen area. There were 2 washing machines available and one of these was not fit for use and was not safe. People told us that a fork had to be used to push a button on the washing machine. Following our inspection we have received confirmation from the provider that both the dishwasher and the washing machine have been replaced. This was completed immediately after inspection.

We checked naloxone, an emergency medicine that can be given in the event of an opiate overdose. Naloxone was locked away in the clinic room and in a locked cupboard. All naloxone was out of date and had expired in June 2025. Since our inspection the provider have replaced and made naloxone easily accessible in an emergency.

There were no alarms for staff or people to use in an emergency. Bedrooms were located on two floors and there was a group room and one to one room located at the end of the garden. In the event of an incident, this would be isolated from other members of staff or people. Managers told us that radios were available for people that might need it, including disabled people. There was a lone working policy in place. This stated that where risks were identified, it should be recorded in the person’s risk assessment and risk management plans should be put in place.

However, people told us they felt safe and they would discuss concerns with staff if they did not feel safe.

There was a fire risk assessment in place that was completed in May 2025. Actions had been identified from the risk assessment to ensure environment safety, which included remedial work on fire doors in the building.

Liberty House was a medically-monitored service, meaning that there were no doctors or nurses based onsite. Physical health checks on admission to Liberty House were completed by support staff and not by a medical professional. This included blood pressure, pulse, respiration and temperature checks. Thorough physical health checks were not completed by a qualified nurse or doctor. Managers told us that results from checks carried out were shared with the assessing doctor as part of their admission assessment.

The staff team consisted of a manager, therapy staff, support staff, housekeeping, a chef and two addiction specialist GP’s that were not based on site. The service did not have a registered nurse in post, however managers told us that they could contact a nurse at another UK Addiction Treatment Centre if support was needed. There was a registered manager in post.

We reviewed the service’s training matrix and found that most staff were in date with mandatory training. Most staff had completed training on opiate overdose and how to administer naloxone in an emergency. Naloxone is an emergency treatment of known or suspected opioid overdose. Staff had not completed training in basic life support.

At the time of inspection there were 2 staff vacancies for a lead therapist and a weekend housekeeper. This was a reduction in vacancies from the previous month, where there were 4 staff vacancies. Staff sickness was 17.2% in August 2025.

Managers provided supervision where staff could discuss case management and received personal support. Supervision compliance was 98% for the last 12 months and appraisal compliance was 93%, with one person not having an appraisal completed.

We reviewed staff files to ensure safe recruitment processes were in place. In the files we reviewed we found evidence of Disclosure and Barring Service (DBS) checks and risk assessments where needed. For example, in one staff file we found evidence of a pregnancy risk assessment being completed.

Staff kept the environment visibly clean. We observed cleaning taking place during our inspection. We reviewed the service’s cleaning rota and found that regular cleaning took place. Audits were completed regularly. For example, there were regular audits of the laundry room to monitor compliance. People told us that regular cleaning took place, however occasional deep cleans were needed.

There was a comprehensive infection prevention and control policy, which included the use of Personal Protective Equipment (PPE), guidance on storing medication and guidelines for safe handling and disposing of sharps, including needlestick injuries. The policy also detailed roles and responsibilities of managers and staff. However, we observed a small clinical waste bin in the main office. Staff told us this was used for urine drug screen disposal but was not located next to the toilet where urine drug screens would take place.

There were handwashing facilities available, however there was not an examination couch in the clinic room.

The service did not have an effective process for ensuring stocks of emergency medicines were kept in date. We found that stocks of naloxone were out of date. Naloxone is a potentially life-saving medicine when used in settings associated with opiate misuse and overdose. Staff and clients need to have access to naloxone for use in a potential overdose of opiates. Following the inspection, the service provided evidence that the stock had been replaced, and staff had access to in date emergency medicines.

Medicines were not always disposed of in a timely way and records were not always kept in line with legislation. We saw that not all controlled drugs for return to the pharmacy were recorded and found that some medicines had not been returned to the pharmacy for over 6 months. Leaders told us that they were working to improve this process with local pharmacy services. The records of administering controlled drugs had improved since the previous inspection.

However, staff followed national practice to check people had the correct medicines when they were admitted to the service. All people were seen by a doctor for an assessment on admission. We saw that GP summary care records were routinely reviewed before being admitted. This had improved since the previous inspection. The doctor reconciled their existing medicines and prescribed them on the electronic prescribing system. People were supported to manage their own regular medication when ordering from their own GP.

Medicines, including controlled drugs, were generally managed in line with national guidance and legislation. Medicines were kept secure with access limited to authorised staff only. The service had clear processes for ordering, storing and administering medication, which was followed by staff. The staff used an electronic medicines management system to ensure that medicines were administered and managed safely. Whilst the service kept large volumes of stock, they were working to review stock levels to ensure that stocks were kept to a minimum.

Staff received medicine related training to support them to safely carry out their role. This included medicines management training and additional training on managing alcohol and opioid detoxification. Staff competency was regularly assessed and recorded by leaders.

Leaders completed regular checks and audits of medicines management and medicines administration records. Staff knew how to report medicine related incidents. We saw evidence of the service working with other agencies to resolve discrepancies of controlled drugs.