Residential Rehabilitation Services: recommendations on clinical governance

Background and Context

RR is recognised within Scottish policy as a Tier 4 treatment option for individuals with complex substance use needs and for policy and research purposes is defined as;

“Facilities offering programmes which aim to support individuals to attain an alcohol or drug-free lifestyle and be re-integrated into society, and which provide intensive psychosocial support and a structured programme of daily activities which residents are required to attend over a fixed period of time”^[1]

Despite this recognition, RR is not treated as a single category for regulatory purposes. Providers operate under different frameworks—Healthcare Improvement Scotland (HIS), the Care Inspectorate (CI), and NHS governance structures—creating inconsistencies and gaps in oversight. Further information is included at Annex A. Concerns raised to the Future of Residential Rehabilitation Working Group (FRRWG) and Scottish Government officials include:

• Inadequate clinical assessment and detoxification planning.
• Poor monitoring during detoxification and recognition/insufficient management of complications.
• Limited staff training and competence in delivering safe detox care.
• Delays in access to detox services
• Requirement that individuals are often required to reduce medication to sub-therapeutic levels, increasing risk.
• Lack of assurance where providers operate outside formal inspection regimes. It has been acknowledged that many detoxes take place in acute medical settings, which is not the ideal setting and a specialist detox setting is preferred.

The National Flexible Framework, introduced in 2024, seeks to standardise approaches to commissioning placements in residential rehabilitation, including detox and aftercare and has improved transparency and contractual standards for participating providers. However, not all services have joined the framework, and regulation remains fragmented. The framework supports, but does not replace, statutory regulation and inspection, making it essential to identify gaps in the current regulatory system. There is no distinct or single designation for RR within regulatory systems, meaning RR services can be variously regulated as housing support, care homes or independent clinics, which may not adequately cover the range of service offered and resulting in blind spots where clinical care is poorly monitored.

Evidence from England reinforces these concerns. The Care Quality Commission (CQC) reported in 2017 that many independent sector services failed to provide safe detoxification, citing poor assessments, inadequate monitoring, and improper handling of controlled substances. Similar risks may exist in Scotland without robust governance.

Further, there is no comprehensive dataset on detoxification practices, outcomes, or adherence to guidance in RR settings. This lack of data limits the ability to evaluate clinical effectiveness and improve standards. Workforce challenges persist, with some services relying on staff without appropriate clinical training to manage complex detoxification.

In summary, while RR plays a critical role in Scotland’s treatment system, governance gaps, inconsistent standards, and limited data undermine safety and quality. Addressing these issues is essential to ensure public confidence and improve outcomes for individuals seeking recovery.