This was an unannounced focused inspection. We went back to check on the progress that the provider told us they had made since our last inspection on 12 July 2016. At that time we issued a warning notice due to a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regulation 15 (premises and environment).

During this inspection, we assessed how the provider had addressed those issues raised. We found significant improvements had been made and that the provider had met the requirements of the warning notice. We found:

• The building was clean and well maintained

• a deep clean of the building had been undertaken

• an increase in domestic staff had been employed to establish cleaning routines and improve standards

• cleaning schedules and guidance for clients to follow were available

• the provider had replaced or refurbished all of the bathrooms and toilets

• furniture had been replaced and there was more on order.

We had not planned to review the progress that the provider had taken in relation to a requirement notice. However, we saw improvements had been made. Immediate remedial action had been taken and there was an action plan to address a range of fire safety improvements. The provider was due to meet with the landlord to review outstanding actions.

• An external fire contractor had undertaken a detailed fire risk assessment of the building

• the provider was addressing the fire assessment

• all fire doors were closing appropriately

• a detailed zone map was placed by the fire panel.

We do not currently rate independent standalone substance misuse services.

We found the following issues that the service provider needs to improve:

• There was non-compliance with infection prevention requirements and fire prevention requirements.

• One to one time with a named key worker was not happening as often as required.

• There was no standalone risk assessment and risk management plan being used.

However, we also found the following areas of good practice:

• There had been recent improvements in the governance arrangements within the service

• Clients felt fully involved in their treatment plans andthat their care needs were being met in all areas

• Staff were receiving regular supervision, appraisal and had access to required training. There were the appropriate numbers of staff on duty.

• The service employed staff and volunteers with lived experience of addiction. This was in line with the recommendations of the Strang report (2012).