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Source · CQC inspection

No. 3

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

Archived This service was archived (deregistered) by CQC on 29 Sep 2022. The ratings below are historical and do not reflect a current service.

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 The provider must have effective processes for reviewing and updating guidance in out of date policies.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