Liberty House Clinic Limited

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• 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.

At our last assessment we rated this key question as good. At this assessment the rating has remained as 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 felt respected, supported and valued. Governance processes operated effectively. There were regular meetings taking place, including clinical governance meetings. There was evidence of innovation taking place in the service.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us their values were to provide a high quality service for people using the service.

Managers had a clear vision and strategy for the service. Initiatives were underway to streamline procurement. The service’s procurement strategy included value for money, compliance and transparency, sustainability and developing long term partnerships with key suppliers. Areas under review included food procurement, energy procurement and waste management. Clearly defined goals enabled managers to provide effective and efficient services.

Leaders had a good understanding of the service they managed and had the knowledge and skills to perform their roles. Staff told us they felt supported by managers and that managers had good leaderships skills. Staff told us that managers were visible within the service.

There was a whistleblowing policy in place, which explained the steps for staff to take if they wanted to raise concerns. Staff told us they felt they could raise concerns. This is important because it helps services to be transparent, accountable and creates a culture where staff feel valued.

People had opportunities to give feedback in community meetings and there was a suggestions box available for people to provide feedback to the service. One person told us the suggestion box was not regularly checked. Since our inspection we have seen evidence that managers responded to suggestions and a new activities timetable has been implemented.

There was an equality, diversity and inclusion policy in place, which was last reviewed in August 2025. Staff told us they would be able to work flexibly if and that reasonable adjustments would be made where needed. For example, staff told us that when there were Muslim team members, they were given time to pray in a private space.

Clear systems were not in place. For example, processes were not in place to ensure naloxone was in date and available in an emergency. Staff were not aware of processes to manage risk of suicide, such as where to access ligature cutters.

However, managers held regular clinical governance meetings, where there was a clear agenda. This included health and safety, incidents, risk assessments, clinic risk register, complaints and patient experience. Managers also discussed learning from incidents. For example, we found evidence of learning being identified when a person was unhappy with their detoxification prescription. Learning identified was that there should be better communication around treatment plans.

Handover meetings had a clear agenda and were attended by the multi-disciplinary team. This included the clinic manager, therapists and support workers. The agenda included a discussion about each person in treatment, safeguarding concerns and any incidents that had occurred.

The service had a risk register. Risks were recorded and mitigation was clear. For example, medication errors had been recorded as a risk and mitigation included training for staff and an increase in observations and audits.

There was a business continuity plan in place for events that might impact the day to day running of the service. This was last reviewed in March 2025.This included events such as loss of electricity, gas or water. The plan also documented contact details for senior members of staff if required in emergency situations.

The service worked alongside key organisations to support care provision. This included local GP walk in centres, social care and community drug and alcohol services where appropriate. Working alongside other organisations and sharing information meant that people received better support for their needs.

Innovations were taking place at the service. Managers told us they were working alongside NHS Trusts to implement FibroScans at the service to check liver health. This would be to identify people with liver disease and support with access to treatment.

The service used KIPU case management system. Managers implemented a KIPU check and compliance system, where daily compliance checks could be completed. This meant that themes could be identified and actions could be taken in a timely manner where gaps were found. Managers also completed a successful trial of KIPU Artificial Intelligence (AI), which will be implemented to support therapists with note taking and documentation.

Managers told us they have listened to feedback from people in community meetings and planned to implement a new activities timetable, which will include low impact physical activity, as well as art projects and recovery focussed book clubs.