Source · CQC inspection

No. 3

Type Independent Healthcare Org Region South East Last inspected 12 May 2022

Overall rating: Requires Improvement  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Good
Well-led
Requires Improvement

Earlier inspection findings

pre-2024 framework · 3 must-do 6 should-do

Must-do actions (3)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 3
Must do
Safe
The provider must ensure staff have training on detoxification and supporting clients through recovery.
Regulation: Regulation 12 (2)(b)
⚠ Not all staff had detoxification and recovery training relevant to the service.
Must-do action 2 of 3
Must do
Well-led
The provider must ensure there is an effective governance processes and oversight to effectively monitor the quality of care being delivered. The provider must have a risk register to demonstrate and review knowledge of their biggest risks. The provider must have effective processes for reviewing and updating guidance in out of date policies.
Regulation: Regulation 17 (2)(a)
⚠ There was a lack of oversight and quality assurance processes were not fully developed. The service did not have a risk register and had no audit programme to evaluate the quality of care provided. Not all policies were current.
Must-do action 3 of 3
Must do
Well-led
The provider must ensure all relevant information regarding the employment of staff must be completed.
Regulation: Regulation 19 (1)(b)
⚠ There was a lack of relevant information regarding the employment of staff. There were gaps in employment history and missing references.

Should-do actions (6)

Recommended improvements to enhance service quality.

Should-do action 1 of 6
Should do
Effective
The provider should have processes to oversee staff’s understanding and application of the Mental Capacity Act.
Should-do action 2 of 6
Should do
Well-led
The provider should consider more formal mechanisms to enable staff to give feedback about the service.
Should-do action 3 of 6
Should do
Well-led
The provider should develop their vision and strategy for the service and share with the staff.
Should-do action 4 of 6
Should do
Well-led
The provider should set staff productivity measures related to recovery or well-being. The service should consider setting staff objectives to improve their skills or develop the service.
Should-do action 5 of 6
Should do
Effective
The provider should undertake staff supervision and appraisals in line with provider policies.
Should-do action 6 of 6
Should do
Effective
The provider should provide staff with a comprehensive induction which includes both environment and client focus.

Location details

CQC ID: 1-10331987699
Local authority: Kent
Region: South East

Inspection report

Type: Inspection report
Date: 12 May 2022
Rating: Requires Improvement
Actions: 3 must-do 6 should-do
AI-extracted 17 Feb 2026