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Inspection carried out on 27 May 2021

During an inspection looking at part of the service

This was an unannounced focused inspection, undertaken due concerns about the quality of risk assessments, the safety of clients, the quality and outcome of investigations and the overall management of governance systems.

We did not look at all key lines of enquiry during this inspection. However, the information we gathered provided enough information to make a judgement about the quality of care. We have reported, but not rated on the following domains:

• Safe

• Effective

• Well Led

Asana Lodge was registered by the Care Quality Commission on 20 April 2020. New services are assessed to check they are likely to be safe, effective, caring, responsive and well-led. The Care Quality Commission has not carried out any previous inspections at Asana Lodge.

We did not rate this inspection. However, we found the following areas of concern:

  • The provider had not ensured staff were adequately trained to provide safe care and treatment to clients. Staff had not received adequate training, supervision, appraisal or induction. Staff were not trained in Mental Capacity Act and did not discuss or check capacity to consent to treatment with clients on admission.
  • Leaders did not have the skills, knowledge or experience to perform their roles, or have a good understanding of the service they managed. The provider did not have systems and processes in place to manage risks to both staff and clients. The provider did not complete regular audits of care provided to clients and had no way to monitor the effectiveness of the service. The provider did not effectively or robustly investigate poor staff performance. The provider had not reported incidents that were notifiable to the Care Quality Commission in a timely manner. Systems and processes for the management of complaints was not effective.
  • Ligature risk assessments were not being completed in line with the providers’ policy.
  • Staff did not adequately assess and manage client risk. Unexpected exit from treatment and crisis plans had not been completed. Staff did not work with clients to develop individual care plans.
  • The service did not have systems and processes to safely prescribe, administer, record and store medicines.
  • The service did not have processes in place to monitor the security of the information being sent to clients from staff members personal mobile phones.


  • All premises where clients received care were clean, well equipped, well-furnished and well maintained.
  • Staff completed routine monitoring of clients’ physical healthcare and regular observations of clients. Staff had completed a comprehensive pre-admission and post admission assessments with all clients. Staff undertook a range of physical health assessments and completed exit questionnaires on discharge.
  • Staff felt respected, supported and valued. Staff felt positive and proud about working for the provider.

This inspection took place on the 27 May 2021. Following our inspection, because of the serious concerns we had about client’s safety, we served an urgent Notice of Decision. We told the provider they must not admit any new clients without the prior written agreement of the Care Quality Commission. We told the provider they must ensure that all incidents, past and present are reviewed and investigated and all notifications requiring submission to the Care Quality Commission are completed in full. We told the provider they must undertake a review of all clinical records, such as care plans and risk assessments for all clients, they must complete a review of all ligature risk assessments and complete an action plan to mitigate all risks identified. We told the provider they must carry out a review of staff qualifications and they must submit evidence of their application for a Home Office Stock license. We also told the provider they must undertake a review of all governance systems and processes at Asana Lodge and devise appropriate policies.