We rated Clouds House as good because:

• Staff provided safe detox and treatment for clients based on national guidance and best practice. Pre-admission assessments used by the service were high quality and included questions which assessed current substance use, risk of blood borne viruses and physical health needs. Staff used the pre-admission assessment to develop risk assessments, on admission, to guide development of individually tailored detox medication regimes. Staff regularly reviewed the effects of medication on each client’s physical health and used nationally recognised tools, including the Clinical Institute Withdrawal Assessment for alcohol scale and the Subjective Opiate Withdrawal Scale.

• Recovery treatment was provided based on the 12 step model. The environment was fit for purpose and there were adequate rooms to provide psychosocial therapies, activities, and safe detox. All areas were safe, clean, well-equipped, well furnished and well maintained. The design, layout, and furnishings of the service supported clients’ privacy and dignity.
• Staff were skilled, competent and knowledgable in meeting the needs of people who used the service. The service provided training in key skills to all staff and made sure everyone completed it. The service had ensured all registered nursing staff had completed part 1 of the Royal College of General Practitioners certificate in the management of drug misuse and the clinical lead had completed part 2. Psychosocial therapies were provided by qualified counsellors and psychotherapists. Staff had completed monthly topical training on substance misuse subjects. Managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care.
• Clients were positive about the service and staff treated clients with compassion and kindness. They respected privacy and dignity, and supported their individual needs. Staff involved clients in decisions about their care, treatment and changes to the service.
• Staff supported clients to make decisions on their care for themselves. They understood the service policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly when appropriate.
• The service treated concerns and complaints, and client safety incidents seriously. The service provided a variety of forums for clients and staff to give feedback on the service and raise any concerns or complaints. There were systems in place to record, review and discuss complaints and incidents and there was evidence of improvement in response to this. The service monitored service risk through a local and corporate risk register which staff could contribute to. Changes to the service were discussed with clients and staff.
• Leaders within the service were visible and approachable for both clients and staff. Staff morale was high and the staff team felt respected and valued. The nursing team and counselling team worked well together and were supported by their managers.

However:

• Staff did not always complete all sections of risk management and care plans. Staff did not regularly review risks and progress within care plans. Six out of seven care records did not have risk assessments completed for the ‘aftercare’ section of the management plans. Risk assessments and care plans had only been reviewed in one care record of the seven reviewed.
• Although staff were managing the risks, documentation of the ligature point risks and plans to mitigate the risks were incomplete (a ligature point is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation). The checklists database for care records, which staff were expected to complete, was not up to date. Although clinical care record audits were being completed monthly, these had highlighted issues with reviews of care plans for three consecutive months without significant improvement or an action plan being developed.
• Some of the blanket restrictions used did not include a clear rationale for their use in the consent paperwork. This included, restricted times to watch television, and set bedtimes without access to other areas of the building. The service did not have a plan or policy in place for reducing restrictive practice.

We undertook this inspection to find out whether Clouds House had made improvements to the residential substance misuse service following the last comprehensive inspection of the service in October 2016. We published our report in early February 2017, and told the provider to take the following actions:

• The provider must ensure that all care plans, including those that detail physical health needs are reflective of individual needs and that they are client centred, holistic and created in partnership with clients.
• The provider must ensure that where processes are in place to allow nurses to administer certain medicines without a prescription when clients first arrive at the service, that the framework that allows this practice to happen lawfully is signed by a qualified pharmacist.
• The provider must ensure that it reports all relevant incidents and safeguarding events to the CQC as is their statutory responsibility.

At this inspection, we found that they had met all the requirements stated above. The service now completed detailed assessments and care plans for each new client when they were admitted. They had also put Patient Group Directions in place so they could administer medicines to clients who had just been admitted to the service. They were also correctly notifying the CQC of any incidents and safeguarding events when needed.

People we met at Clouds House told us they were treated with privacy, dignity and respect. They said staff were considerate and demonstrated through training and experience how they understood people's needs. People said they knew the ethos of Clouds House and how the recovery programme worked. People were involved with how their treatment was delivered and understood how they were expected to participate. One person had some concerns around respect for equality and diversity. We discussed this with senior staff and asked them to look into these concerns more thoroughly and respond to this person.

We found staff had a clear understanding of privacy, dignity and respect. They demonstrated how this flowed through everything they did at Clouds House. People were given good physical care and the organisation provided both counselling and psychiatry for people's mental health needs. The organisation had all the relevant medical equipment on site and that for use in an emergency. It was all checked and monitored regularly.

Staff were recruited safely and all the appropriate checks and processes were followed. The organisation supported this with qualified and accredited human resource professionals. We reviewed records and found they were fit for purpose, held securely and destroyed safely at appropriate times. The nursing records were comprehensive and carefully managed. There were good counsellor records, although some forms were not being updated on occasion and there was some uncertainly as to their use among staff.

When we visited Clouds House we sat and talked at some length with five of the people staying for rehabilitation treatment. They all told us they felt cared for, respected and supported by staff. A person who had recently arrived said they felt "so safe." We were told all the staff were kind, warm and friendly, from housekeeping through to senior management. The counsellors were said to be "amazing" and "they always have time for you." We were told the food was "wonderful" and people said they were feeling mentally and physically better.

Staff told us they had a collaborative approach to the treatment programme people were undertaking. The nursing staff ensured they worked alongside GPs, counsellors and therapists to act in people's best interests. As well as helping them with their other health problems, they listened to people and negotiated with them to try to reduce the risks of habitual addiction behaviour.

We found the service was managing medicines safely and effectively. All the equipment required in case of a medical emergency was available. The premises were clean, warm and well maintained. Staff were well supported and trained. Their competency was assessed through regular progress reviews and other meetings as well as an annual appraisal.

The organisation had an effective system to assess and monitor the quality of the service. This included audits, learning from adverse events, and regular service reviews with staff across the organisation.

People expressed their appreciation of the service’s therapeutic approach. One person told us “I think it’s brilliant”, another it was “much better” than a treatment programme at a different provider. People told us they had full information about the service before their admission. People we spoke with told us they felt able to bring up matters with their counsellors, nursing staff and each other. People expressed their appreciation of the staff. One person said the nursing staff were “more than competent” and another, said they were “completely satisfied” with the skills of their counsellor.

• There were very few staff vacancies at Clouds House. Remaining vacancies had all been recruited to.

• The environment was clean and well maintained. Staff were aware of infection control procedures.

• The mixed sex environment was well managed.

• Medicine management procedures were improving due to better incident reporting when errors had occurred. In addition, the provider now had in place the correct procedures related to the storage of controlled drugs. This had not been the case previously.

• Group and individual therapies were being delivered in line with national guidance.

• There were regular staff meetings through the day that ensured clear handovers of detailed client information.

• Prescribing arrangements were in line with national guidance and best practice.

• All patients received a physical health assessment within 24 hours of admission

• Clients described feeling extremely well cared for and supported by the staff. Clients were involved in their care and treatment throughout their stay.

• Clouds House made adjustments for clients who had specific needs in order to ensure they could provide treatment.

• Community meetings were held weekly.

• Family members were involved in the treatment process when this was appropriate and with clients consent.

• Clients with specific needs, including people who were pre and post-operative transgender, were being fully supported by staff.

• There were various routes for admission. Where people were unable to self-fund or were not referred by the NHS, Action on Addiction would financially support client’s admission. The admission assessment process was thorough and explored the client’s needs in their entirety.

• There was a range of recreational activities available for the clients.

• The environment and location were set in in grounds that promoted privacy, relaxation, comfort and recovery.

• There were very few complaints received from clients but all were dealt with and responded to appropriately.

• Staff told us that senior staff were visible and accessible and that they provided guidance and support.

• The service had a clear vision and set of values that staff understood and staff morale was very high.

• There was a risk register which was subject to review through the clinical governance group.

• Statutory and mandatory training figures were high.

• Safeguarding issues were followed up, recorded and reported to the appropriate agencies, such as the police and local authorities. There was a process for the reporting and managing of incidents at Clouds House.

• Clients who required high dose methadone were assessed prior to admission and underwent a longer period of detoxification.

• However, we also found the following issues that the service provider needs to improve:

• Although a plan had been formulated to ensure that moving forward staff received supervision, at the time of our inspection, not all staff were not receiving regular clinical or line management supervision.

• Care records we reviewed did not contain comprehensive, detailed and holistic care plans for clients. Generic care plan templates were being used. In addition, where physical health issues had been identified during the assessment, these did not translate into care plans.

• There were many ligature points around Clouds House. The organisation had not undertaken a ligature risk assessment at the time of the inspection. This has since been completed and submitted to the CQC. Assessments relating to individual risks were being completed prior to and during the admission process.

• Clouds House were not reporting any incidents or safeguarding events to the CQC as is their statutory responsibility.

• Post inspection, Clouds House submitted evidence to show that catering staff had completed food hygiene training and bank staff were trained in life support. However this was not clearly reflected on the training matrix at the time of our visit.