ESH Community

On this page

• 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 good. At this assessment the rating has remained good.

The service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The leadership team was proactive and committed to delivering high quality care for patients. Leaders were visible, accessible and actively involved in the day‑to‑day running of the service. Governance arrangements supported oversight of quality, risk and staffing, and leaders promoted a culture that prioritised recovery, safety and learning. Systems for assurance, staff support and partnership working were embedded and used consistently.

We have not awarded this service a score for Well-led.

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

Staff described a consistent focus on recovery, safety and sustained outcomes beyond discharge. The service followed a 12 steps programme to recovery, and staff consistently described sustained recovery as the overriding aim of the service. Staff and leaders recognised that people were at different stages of recovery and required differing levels of support to maintain progress.

All multidisciplinary team staff told us they understood the service’s purpose and how their role contributed to it. Staff were clear about their responsibilities and how they worked together to support people through detoxification, rehabilitation and onward recovery. Leaders reinforced expectations through regular team meetings, daily handovers and their visible presence within the service.

Staff had opportunities to contribute to discussions about the direction and development of the service, particularly where changes were planned. For example, staff had contributed to the service’s website contents and were involved in shaping the development of a new lodge used for pre‑admission assessment.

Team meeting minutes from the last 3 months showed shared discussion of admissions, resident progress, discharge planning, risks and learning. Staff described feeling positive about working at the service and told us they felt valued members of a supportive team. Feedback from staff included staff describing that they felt “really good” working at the service and supported by colleagues and managers when challenges arose.

The culture observed during group sessions and meetings demonstrated openness, mutual support and a shared commitment to recovery.

Leaders had the skills, knowledge, experience and credibility to lead effectively. The registered manager had been in post since the service registered with CQC and had extensive experience in substance misuse services. The consultant psychiatrist had significant experience in mental health and addictions and clearly explained how the multidisciplinary team worked together to deliver high‑quality, person‑centred care.

Leaders were highly visible, approachable and compassionate, and maintained a consistent presence within the service. Staff told us senior leaders, including the registered manager, operations manager and consultant psychiatrist, were regularly present, accessible and supportive. Staff spoke very positively about leaders, describing how they role modelled empathy, recovery‑focused practice and professionalism, and how this made them feel respected, listened to and psychologically safe.

Leaders were highly visible, compassionate and inclusive, and were highly trusted by staff and people using the service. Leaders were visible within the service and accessible to staff and people using the service.

Leaders maintained close oversight of care delivery and staff wellbeing. We saw evidence of regular operational supervision, annual appraisals and ongoing informal support. Staff told us it was easy to raise concerns and that leaders actively listened and responded to their views, particularly when discussing people’s care.

Leaders used lived experience appropriately to strengthen engagement and trust with people using the service, while maintaining clear professional boundaries. This inclusive approach was reflected in positive feedback from people using the service and their relatives, who described leaders as open, reassuring and consistently involved in care. People using the service and relatives described leaders as visible and involved, which they said helped them feel reassured and supported.

Leaders also demonstrated a strong commitment to developing future leadership capacity and sustaining high‑quality care. The operations manager had completed an NVQ level 5 and was progressing towards becoming a registered manager. Leaders supported staff to access bespoke training and development opportunities, enabling them to build skills, progress into leadership roles and contribute to continuous improvement.

The service created an environment where staff and people using the service felt able to raise concerns and provide feedback, and where this was listened to and shared appropriately.

Staff told us they felt safe to speak up and raise concerns without fear of negative consequences. Staff described the level of work‑related stress as manageable and said they felt positive about their duties. Staff told us leaders were approachable and that concerns could be raised through one‑to‑one supervisions, team meetings and informal discussions.

There was no separate formal freedom to speak up process in place at the time of the inspection; however, the provider engaged openly with families and carers, had a whistleblowing policy in place, and all staff we spoke with confirmed they knew how to use the whistleblowing process and felt confident raising concerns without fear of victimisation.

Staff demonstrated a clear understanding of whistleblowing and its application. Staff said this openness supported effective team working and a positive working environment.

People using the service and their relatives had opportunities to give feedback through multiple channels and in a manner that reflected their individual needs. These included informal discussions during one‑to‑one sessions, exit questionnaires, a suggestion box and direct contact with the provider. Staff told us feedback from people using the service was shared during weekly team meetings and used to reflect on practice and discuss areas for improvement. Staff had access to the feedback from patients, carers and staff and used it to make improvements. Patients and carers were involved in decision-making about changes to the service.

We reviewed 4 exit questionnaires completed between December 2025 and March 2026. All feedback reviewed was positive. Two relatives we spoke with said staff explained the basis of their work clearly and told us they felt reassured and supported.

Staff told us that, should concerns or incidents arise, these would be discussed openly within the team and learning shared.

All staff had completed mandatory equality and diversity training in the last 6 months. Leaders supported reasonable adjustments for staff where required and used supervision to discuss wellbeing, boundaries and professional development. Staff reported that the provider promoted equality and diversity in its day-to-day work.

Staff told us the service valued lived experience and diverse backgrounds, and that differences were respected within the team. Recruitment processes were inclusive, where required, appropriate risk assessment and management arrangements were completed and reviewed.

Leaders also supported staff work–life balance. Staff described flexible rota arrangements that alternated working commitments across weeks, which they told us helped them manage their workload alongside personal responsibilities. Staff said this approach contributed to manageable levels of work‑related stress and supported their wellbeing at work.

The service had effective governance and management systems to monitor quality, manage risks and support sustainability.The service used a structured governance framework to oversee quality and performance. Records showed there was a consistent agenda for service‑level discussions, so essential information, including learning from complaints, was shared and reviewed. Weekly team meetings were held to ensure information was communicated across the staff team. Minutes showed staff discussed prospective, current and previous people using the service, including assessments, risks, treatment progress, peer dynamics and agreed actions to resolve issues.

Complaints and feedback were monitored and acted on at service level. The log and meeting records showed concerns were followed up and used to make improvements, including actions relating to the environment, expectations of staff conduct, and access to recovery activities. Learning from complaints was also discussed in team meetings to reinforce expectations and reduce recurrence.

The service used audit activity to provide assurance and support improvement. This included infection prevention and control (IPC) audits, environmental and fire safety checks, and routine review of risk assessment, care records and medicines management processes. Audit findings were discussed with staff and informed updates to documents and processes, including admission, induction and aftercare information.

Leaders also monitored the premises and health and safety. All 13 maintenance issues raised in the last 3 months had been resolved within agreed time frame and responsibility for logging and oversight was clear. All fire risk assessment related actions had been completed within the last 3 months with mitigating steps recorded. Records also showed weekly fire system checks, 6‑monthly servicing and quarterly fire drills.

Risk management arrangements were in place and understood by staff. Staff told us they could submit items to the provider’s risk register and escalate concerns to senior staff. Board minutes showed oversight of quality, performance and risk, including staffing, insurance, health and safety, business continuity and information governance. A risk matrix form and guidance described actions expected according to risk level.

The provider had arrangements to support sustainability and continuity. A business continuity plan set out how the service would maintain safe delivery during disruption, covering staffing, IT systems, supplies, health and safety and safeguarding. The plan included information governance requirements, clear responsibility for activation and links with external agencies, including the Care Quality Commission and the Warwickshire Multi‑Agency Safeguarding Hub (MASH). Risks were reviewed through board‑level oversight.

Information governance systems supported confidentiality and access to essential information. Staff had access to the equipment and information technology needed to do their work, and managers had access to performance and staffing information in both electronic and paper formats. The provider reported an upgrade to Microsoft 365 in January 2026 to improve communication, information governance and IT reliability.

The service worked effectively with partners and the wider community to support people’s recovery.

Staff described active engagement with GPs, community substance misuse services and dry house organisation, which provides shared, substance‑free accommodation where people live in a structured environment to support ongoing recovery and maintain sobriety.

We saw evidence of joint working during admissions, detox support and discharge planning. Residents were supported to attend external recovery meetings and ongoing aftercare sessions.

Relatives told us that the service was responsive, and that they felt involved with the person’s agreement.

The registered manager worked with external stakeholders, including commissioners. People using the service and staff had opportunities to share feedback directly with members of the provider’s senior leadership team.

Leaders consistently used reflective practice, supervision and team meetings to review practice and strengthen systems. Records and staff feedback showed learning from previous concerns had led to improvements, including more robust audit processes and enhanced pre‑admission assessment arrangements.

Leaders told us they were sharing their detoxification and rehabilitation model and best practice with another organisation to support the development of safe and effective of delivering detox (Detox is a short period of medically monitored support to help people withdraw safely from drugs or alcohol and manage physical and psychological symptoms.) care.

Innovation was embedded in service delivery. The service continued to use technology to support safety during detox, with monitoring arrangements reviewed and reduced as risks decreased. Leaders were also developing a purpose‑built admissions lodge to improve the environment for assessments, admissions and structured involvement of families

Leaders responded proactively to changing needs. Following feedback from people who used the service, the provider had introduced new treatment pathways, including shorter and more flexible detox and treatment packages, to improve accessibility and responsiveness for people requiring shorter stays.

The service also demonstrated innovation in sustainability and self‑sufficiency. Staff told us the service operated its own sewage treatment system and grew some of the food used on site, supporting environmental sustainability alongside care delivery.