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• 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 inspection, we rated this key question as good. At this assessment, the rating has remained good. This meant people were safe and protected from avoidable harm.

The service assessed and managed risks to people and staff well. Staff understood how to safeguard people from abuse and worked effectively with other agencies when required. The service used systems and processes to safely assess, monitor and manage risks, including the safe management of medicines. The service managed patient safety complaints appropriately and used learning to improve practice.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

There had been no serious incidents reported in the previous 3 months.

The service demonstrated a positive learning culture where incidents, feedback and concerns were openly discussed and used to improve care. For example, concerns were raised about maintaining professional boundaries during shifts. Leaders reviewed this in team meetings, through individual supervision and set clear expectations about staff conduct. In addition, learning from audits and resident feedback led to changes in pre‑admission and induction processes, including clearer communication about counselling starting after detox, which helped reduce anxiety for people at the beginning of their stay and improved their experience of care.

Staff understood how to recognise, report and respond to incidents and concerns, and followed an incident reporting policy to support consistent practice. Staff used a risk matrix and incident management guidance to help assess incidents and determine appropriate actions.

Concerns were recorded, reviewed and discussed in weekly team meetings and supervision sessions. Learning was shared with staff, including those who were not present at meetings, and outcomes were fed back to people involved. Staff told us debriefs took place when required to support learning and wellbeing.

Staff demonstrated an understanding of the duty of candour. They described being open and transparent and ensuring people using the service and their families received clear explanations when things went wrong.

The service had effective systems in place to ensure people moved safely through referral, admission, treatment and discharge. Referral and admission processes ensured that all essential information was obtained to assess whether people’s needs could be safely met. Referrals were managed through the administrative team and discussed within the wider team to support shared decision‑making. The service used risk exclusion criteria to help ensure that only people whose needs could be safely supported were admitted.

Pre‑admission assessments included physical health, mental health and risk information and were reviewed by a consultant psychiatrist prior to admission. The service described a face‑to‑face admission process, with risk assessments completed on arrival and supported by consultant input. Staff told us that risk information and care plans were reviewed and updated throughout people’s stay and were held in both electronic and hard copy formats to reduce risk in the event of system failure.

Staff demonstrated an understanding of risks to people across their care journey, including admission, treatment and discharge. Managers monitored the effectiveness of these systems by overseeing risk assessments and care planning to help keep people safe. Staff assessed and reviewed risks before admission, during treatment and following discharge, which helped reduce the risk of harm and relapse.

Staff began discharge planning early and developed plans with people throughout their stay. Discharge plans included identified risks and agreed safety measures. Where people had given consent, staff involved relatives in discharge planning and continued to support families following treatment to help maintain recovery and effective aftercare. Staff worked collaboratively with GPs and community services to support continuity of care through appropriate information sharing.

The service also provided a structured aftercare programme, including planned follow‑up telephone calls at 14 and 90 days post discharge from treatment and access to weekly aftercare sessions, to support people to remain safe and engaged with ongoing support after discharge.

The service had effective safeguarding systems in place to help protect people from abuse and neglect. All staff had completed level 2 safeguarding vulnerable adults training and understood how to recognise safeguarding concerns and how to make a safeguarding alert when appropriate. Staff knew how to identify adults and children at risk of, or experiencing, significant harm and described working in partnership with external agencies to help keep people safe. Safeguarding policies were in date, contained clear procedures and contact details, and were understood by staff across all roles.

Staff told us they were committed to taking immediate action if anyone’s safety was at risk. Managers described how staff had supported a person who was at risk of self‑harm including putting additional safeguards and support in place to reduce risk and promote safety. There had been no safeguarding concerns raised in the 12 months before the assessment.

Staff were able to give examples of how they protected people from harassment and discrimination, including people with protected characteristics under the Equality Act. The service also considered risks to children visiting the service and followed safe procedures, working with external agencies where required to help ensure children were protected.

Mental Capacity Act and Deprivation of Liberty Safeguards

The service did not apply for Deprivation of Liberty Safeguards (DoLS) authorisations, as people were free to leave at any time. Staff described how they would support people safely if they chose to leave treatment early, including ensuring people reached a safe destination and informing families and relevant professionals in line with agreed policy.

All staff had completed Mental Capacity Act (MCA) training in the last 6 months. Staff demonstrated a clear understanding of the Act’s principles and how to apply them in practice to support lawful, proportionate and person‑centred care.

People were actively involved in decisions about managing risks to their safety and wellbeing. Risk assessments and personalised risk management plans showed that risks were identified, reviewed and updated throughout people’s care, particularly during periods of increased risk such as detox.

The service used structured approaches to monitor risks during detox, supported by staff oversight and consultant input. At night, staff used alert‑based monitoring linked to all bedrooms to support timely responses, particularly when people were undergoing detox.

Staff explained risks clearly and obtained consent for enhanced monitoring during detox, including door sensors and visual monitoring such as CCTV, which was used during detox and the first 72 hours of admission, or longer where risks remained highest, and was clearly documented and reviewed.

Staff demonstrated a good understanding of risks associated with mental health and substance misuse and took appropriate action to reduce harm. This included using separate building for some face‑to‑face assessments to reduce potential risks to people already receiving treatment and to help individuals feel less overwhelmed, alongside regular daily welfare check‑ins to monitor wellbeing. People were informed about identified risks, supported to understand how to keep themselves safe, and told us they were involved in their care, which was reflected in records reviewed.

Environmental risks were assessed regularly. The building was clean, well maintained and suitable for the number of people using the service.

Although the environment could accommodate up to 11 residents, the service typically supported 6 residents at a time. Environmental risks were reviewed regularly, including checks of fire exits, medicines security and the safe storage of substances hazardous to health (COSHH).

The provider maintained a maintenance log and reported that all 13 maintenance items identified in the 3 months up to March 2026 had been completed. Bedrooms were personalised, communal areas were well used, and clinic rooms were available for assessments and medicines administration. Staff were able to observe people appropriately, including increased observation during detox when required.

The environment supported people’s safety and recovery. In addition to well‑maintained indoor spaces, the service had a large, therapeutic outdoor area that people accessed as part of their recovery programme. Staff told us this space was used for wellbeing activities and quiet reflection, with risks managed through supervision and agreed boundaries.

Fire safety arrangements were robust. A fire risk assessment completed within the last 3 months identified 52 items, with measures in place to manage risks. The provider had a fire system maintenance contract, with weekly alarm tests, 6‑monthly servicing, and a quarterly fire drill completed. Fire alarm detectors in remote buildings had been replaced with interconnected alarms to improve coverage.

Additional systems supported environmental safety, including a logbook to record staff and visitor entry and exit. Environmental risks were also managed through a comprehensive location risk assessment. This assessment incorporated infection prevention and control arrangements, including a daily cleaning rota with clear staff responsibilities.

The service had enough skilled and experienced staff to keep people safe. Over the last 6 months, the staffing establishment was 17 staff, made up of 7 full‑time and 10 part‑time roles, with no vacancies at the time of the assessment. On the day of inspection, staffing levels were sufficient, with a ratio of 7 staff to 4 residents, supporting safe delivery of care. There had been no short‑staffed shifts in the previous 6 months, and staff told us activities were not cancelled due to staffing levels.

Staff turnover was 12.5% over the same period, and posts were filled promptly, including the recruitment of 4 additional staff. Sickness absence was well managed, with a reported rate of 5.4% and no instances of sickness lasting more than 7 days. The provider told us sickness had no impact on the delivery of safe care. The service did not use bank or agency staff.

The service had robust and safe recruitment processes in place. We reviewed staff records for 8 staff, which showed that all had an up‑to‑date criminal record check and suitable references to ensure they were safe and appropriate to work with vulnerable adults.

There was always medical cover available during office hours. The doctor assessed each person, completed medical reviews and made clinical decisions as required. The doctor attended the service regularly and was available outside of this time through telephone and videocall.

Administrative staff supported the day‑to‑day running of the service.

Mandatory training compliance was high at 97.44% over the last 6 months. Training covered areas relevant to the needs of people using the service, including safeguarding vulnerable adults level 2, first aid, safe administration of medicines, mental capacity, health and safety, equality and diversity, physical health monitoring and naloxone awareness.

Staff followed infection prevention and control practices, including hand hygiene, cleaning routines and safe waste management. Cleaning responsibilities were clearly allocated across day and night shifts, including kitchen staff, and infection prevention and control arrangements were embedded within the environmental risk assessment. Cleaning records were up to date and demonstrated that the building was cleaned regularly, with checks completed to provide assurance. Toilets and bathrooms were observed to be clean and tidy during the inspection.

Food safety arrangements supported infection prevention and control. The kitchen log included routine temperature checks for food delivery, storage, cooking and serving, with clear guidance for staff on safe storage temperatures, food labelling and actions to take if standards were not met. All food items were appropriately labelled with defrost and use‑by dates, and allergen‑specific utensils were available to minimise risk. The kitchen environment was clean, tidy and well organised, with clear signage to restrict access. Residents accessed the utility area through a separate entrance with staff support, which reduced the risk of cross‑contamination. Cleaning materials were stored securely in line with Control of Substances Hazardous to Health requirements (COSH).

The service monitored infection risks and staff sickness and encouraged staff not to attend work when unwell to reduce the risk of transmission.

The service had safe and effective systems for managing medicines. Medicines policies were in date, reviewed annually and provided clear guidance for staff. Staff who supported people with medicines were trained, competent and worked within agreed policies and procedures. People usually brought their own medicines into the service from their general practitioners (GPs), and these remained the person’s property while they received treatment. Staff supported people to store medicines securely and to administer them safely.

We reviewed 4 medication administration records (MARs) and found medicines were administered safely and in line with local policy, with no errors identified. Medicines policies had been reviewed in November 2025, and staff compliance with medicines training was 100% in the last 6 months.

Accurate and up‑to‑date information about people’s medicines was available, particularly when people moved into and out of the service. Staff reviewed and reconciled medicines on admission before treatment commenced. Where people gave consent, the prescribing doctor obtained a full medicines history from the person’s GP before prescribing any medicines within the service. Prescriptions were issued in the person’s name and remained in their custody. Staff informed people’s GPs about medicines prescribed by the service, and GPs continued to prescribe medicines for people’s physical health needs. Arrangements were in place to ensure continuity of supply, including GP prescriptions sent directly to local pharmacies or repeat prescriptions arranged where appropriate.

Staff used recognised assessment and monitoring tools to support safe prescribing and medicines management during detoxification. This included the Clinical Institute Withdrawal Assessment for Alcohol (CIWA‑Ar), a validated tool used to assess the severity of alcohol withdrawal symptoms and guide medication use, alongside other validated withdrawal scales where required. Staff completed daily physical observations and risk assessments, and medicines were adjusted or withheld where there were no withdrawal symptoms or signs of over‑sedation.

The consultant psychiatrist oversaw prescribing, emergency medicines and clinical decision‑making, and closely monitored people during detoxification, with staff escalating concerns promptly. Staff reviewed the effects of medicines on people’s physical health regularly and in line with national guidance. This included baseline and ongoing physical health checks such as blood tests and electrocardiograms (ECG), which helped inform safe treatment pathways.

There were appropriate arrangements for the safe management, use and oversight of medicines. There were no controlled drugs in use at the time of the inspection, but clear procedures were in place should they be required. Emergency medicines were available, within expiry dates and accessible to staff. Medicines requiring cold storage were kept in a dedicated medicines fridge, with temperatures monitored and recorded. Staff also completed medicines audits to provide assurance that medicines were managed safely and effectively.