Aspire Havering

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.
This is the first assessment for this service. This key question has been rated Good.

This meant people were safe and protected from avoidable harm.

All areas used to deliver care and treatment were safe and clean. Staff assessed and managed risks to clients and themselves effectively.
Staff understood how to protect clients from abuse and worked well with other agencies to support safeguarding. The service had systems and processes in place to safely prescribe, record and store medicines. The service managed patient safety incidents appropriately. Staff recognised and reported incidents, and the service used these to support learning and improve practice.
However, staff identified some environmental concerns. These included that the reception area felt unwelcoming and that parts of the building were not fully fit for purpose.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learned to continually identify and embed good practice.

The provider reported that there had been no serious incidents in the last 12 months.
The service demonstrated a positive learning culture, where staff were encouraged to reflect on practice and share learning to improve outcomes for people using the service. Learning from incidents and service delivery was routinely discussed in multidisciplinary team meetings, supporting shared understanding and continuous improvement.

There was clear evidence of team learning and learning from incidents. For example, the service had developed a new pathway for patients being discharged from acute hospital settings to continue their detoxification within the community. This demonstrated how learning was used to improve care pathways and ensure continuity of treatment.
Staff understood their responsibilities in relation to incident reporting and told us they knew what to report and how to report it. They used the provider’s in-house electronic recording system to record incidents and share information appropriately.

The service supported ongoing shared learning through structured and informal opportunities. Daily morning briefings were held to share key information and updates. In addition, “bite-size” learning sessions were delivered weekly and were often incorporated at the end of team meetings to reinforce knowledge and promote continuous development.

Staff also had access to scenario-based learning through Integrated Governance Team Meetings (IGTM), which supported them to reflect on real-life situations and strengthen their decision-making and risk management skills. Staff also shared examples of learning related to incident responses, including the use of emotional intelligence and de-escalation techniques. Team-based workshops included role play and reflective exercises, which supported staff to recognise individual strengths and improve their response to challenging situations.

The service was designed to respond to the needs of the local population in Havering. Referrals were accepted from a range of sources, including self-referrals, the local authority, hospitals, mental health services, social services, probation services, and the wider criminal justice system. The service primarily accepted referrals from residents within the Havering borough. In exceptional circumstances, referrals from out-of-borough clients were accepted to ensure individuals are not left without access to support. For example, the service may accept referrals where clients have legal restrictions, such as injunctions, that prevent them from accessing services within their home borough. In such cases, the service works to ensure that individuals can still access appropriate treatment and support for drug or alcohol misuse.

The service had systems in place to support safe access, pathways, and transitions for people using the service. This included pathways for individuals subject to Alcohol Treatment Requirements (ATR) or Drug Rehabilitation Requirements (DRR), and those transitioning from prison. New clients were offered an initial induction, during which staff contacted them to explain the service and discuss available support options. In some cases, individuals accessed elements of the service prior to a full assessment, such as attending SMART Recovery drop-in groups. SMART Recovery supports people to recognise whether they have a problem with alcohol or drugs, build motivation to change, and develop practical skills using evidence-based tools and techniques to support their recovery journey. The service operated a daily high-risk assessment slot to ensure it could respond promptly to urgent referrals and manage risk effectively. Two induction groups for new clients were held each week, after which referrals could be progressed to assessment. Where clients did not attend (DNA) their first booked induction, they were offered a further opportunity; however, this could result in delays to assessment.

At the time of inspection, the average waiting time from referral to triage was 25 days (18 working days), which meant some people experienced delays in accessing structured treatment, although the service had processes to engage clients earlier. The service used a dashboard to provide oversight of caseloads, waiting lists and required actions. However, information on referral-to-treatment times was not always clear or consistently presented. The dashboard showed 177 people awaiting assessment, although leaders explained that some had already engaged with the service through induction sessions or drop-in groups, and others were in acute hospital settings or in prison, which affected the timing of their assessment.

The service maintained oversight through weekly caseload reports and monthly performance reports, which supported staff to manage workload and track waiting times. Managers told us the data did not fully reflect early engagement, with initial contact usually taking place within 2–3 days and face-to-face contact within 6–7 days, and that opiate assessments were prioritised due to higher clinical risk. Data from October to December 2025 showed that 140 clients progressed through assessment, treatment and discharge. The service also worked with partners to support continuity of care, including a hospital liaison nurse based in the acute hospital and close working with a young person’s service to support appropriate referrals. Managers reported work was underway to improve the dashboard, so it better reflected the full client journey before assessment and provided a more accurate picture of access and performance.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. At the time of our inspection, 100% of staff had completed their safeguarding training.

The service had systems and processes in place to identify, monitor and manage safeguarding risks. Safeguarding information was clearly recorded within the service’s electronic records system. A dedicated safeguarding tab was used to store relevant information, including identified risks, actions, and updates. In addition, the system included a visible flag on the front page of client records to alert staff to safeguarding concerns. The caseload overview page also included a red “S” indicator to identify clients with safeguarding risks, ensuring staff could quickly recognise and prioritise individuals requiring additional support or monitoring.

Safeguarding concerns and actions were routinely discussed in daily risk meetings, morning briefings, and zoning meetings, which enabled staff to maintain regular oversight and respond promptly to emerging risks. Staff also highlighted safeguarding issues during multidisciplinary team discussions to support coordinated care and information sharing across services. The service demonstrated a structured approach to reviewing safeguarding practice. Safeguarding cases were reviewed with key workers every six weeks, supported by audits and feedback to identify areas for improvement and strengthen practice.

Safeguarding information was recorded within individual client records on the electronic system. The safeguarding lead told us they were exploring the development of a centralised system, such as an Excel-based tracker, to improve oversight, governance, and the identification of themes, trends, and learning across the service. Overall, safeguarding processes were embedded within daily practice, supported by clear recording systems and regular team discussions

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to clients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We looked at 5 risk assessments and risk management plans during our inspection. Staff created comprehensive risk assessments, regularly reviewed and up-to-date and were developed in partnership with the client. We saw evidence in care records that staff involved clients in care planning and risk assessments.

The service involved people in managing their own risks and supporting safer care. Staff used a zoning approach to maintain oversight of risk levels across the caseload, with key workers responsible for regularly updating individual risk information. This included highlighting and reviewing levels of risk, which supported ongoing oversight of clients who may be at risk of harm to themselves, others, or from others, including risks relating to children. Where risks to children were identified, staff took appropriate action and developed plans to liaise with social services to ensure safeguarding concerns were addressed. This demonstrated a commitment to multi-agency working and protecting vulnerable individuals. The key working template, completed at each contact, prompted staff to reassess risks and ensure that any changes in a person’s circumstances were identified and acted upon in a timely way. This supported continuous risk monitoring and encouraged collaborative discussions between staff and clients about safety and wellbeing.

The service placed a strong emphasis on harm reduction and supported clients to manage risks associated with substance use. This included practical harm reduction advice and safer injecting guidance. Clients were provided with appropriate equipment to reduce the risk of infection and injury, including sterile needles and syringes, sharps bins, alcohol swabs, vitamin C, water for injections, and sterile spoons. Staff also provided naloxone to clients at risk of opioid overdose and ensured they understood how to use it effectively. These interventions supported clients to reduce immediate risks while engaging in treatment and recovery.

Overall, people were actively involved in identifying and managing risks, with staff providing practical support, education, and resources to enable safer behaviours and informed decision-making.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. However, the service records showed equipment was maintained and clean and the service had systems in place to monitor and manage the environmental risks.

The environment was not always suitable or fully fit for purpose. Staff and clients consistently described the building as unwelcoming, and feedback about the premises was less positive overall. Both staff and people using the service told us the environment did not support a positive or therapeutic experience of care.

Environmental concerns were identified during the inspection. We observed evidence of roof leaks, including water-damaged ceiling tiles in the kitchen area, as well as some loose hanging wiring. There was visible black mould on window frames in several rooms, and parts of the building showed signs of wear and tear, including tired paintwork.

These issues had the potential to impact the safety and suitability of the premises by creating environmental risks, and general disrepair.
The service was aware of these issues and had identified environmental risks on their risk register, including risks relating to flooding from pipes above the premises. Mitigation measures were in place and documented, however these were broad and lacked detail to address individual environmental issues.

The registered manager acknowledged the environmental concerns and explained that the building was old, had known structural issues, and was scheduled for demolition. They described interim measures in place to monitor and manage risks associated with the premises while it remained in use. Despite these concerns, the service ensured that equipment was well maintained, clean, and in working order. Records showed that environmental and equipment checks were completed regularly, with the December audit recording 100% compliance. Communal areas and meeting rooms were generally clean and tidy.
Overall, while the condition of the building did not fully support a safe, clean, and welcoming environment, the service had systems in place to monitor and manage the environmental risks.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had systems in place to support and monitor staff performance and wellbeing. The registered manager has oversight of supervision through a supervision monitoring log, which was informed by line managers and supplemented by information from central teams to ensure accuracy and completeness. The organisation required staff to receive a minimum of four supervisions and one annual appraisal. Managers had implemented a more robust approach, with staff booked into monthly supervision sessions and a yearly appraisal, typically completed at the end of a staff member’s first year in post. Staff confirmed they received regular supervision and felt able to discuss their performance, development needs, and any concerns.

In addition to formal supervision, staff had access to end-of-day debriefs to reflect on challenging or distressing situations. These debriefs were available routinely and could also be facilitated by managers following incidents or bereavements, ensuring staff received timely emotional and professional support. Managers supported staff wellbeing and responded appropriately to health needs. At the time of inspection, one member of staff was off sick and being supported. Staff told us managers encouraged them to access the employee assistance programme and provided support when time off was required due to ill health.

Staff received a range of training relevant to their roles, for example, motivational interviewing (MI) which supported staff to develop and maintain their skills and ensured competency in delivering effective, person-centred interventions. Managers told us they identified staff learning needs through supervision and appraisal processes. Staff confirmed they received regular supervision and had access to a range of learning and development opportunities. These included online training modules, as well as the ability to request additional training courses. Staff told us the organisation made efforts to support attendance at training to enhance skills and knowledge within teams. At the time of inspection, the service had vacancies within the team. There were two vacant posts funded through government grant funding (a recovery practitioner and a criminal justice practitioner), and one additional vacancy for a recovery practitioner (non-opioids) funded through the core budget.

Staff provided positive feedback about the leadership of the service and described a supportive team culture with a strong focus on recovery. However, some concerns were raised in relation to staffing levels and workload. Four out of 18 staff told us that staffing pressures and turnover impacted their ability to manage caseloads safely. Some staff reported feeling overwhelmed or lacking sufficient structured support at times. At the time of inspection, the service managed approximately 525 clients per year, equating to an average caseload of around 55 clients per staff member, including both alcohol and opiate clients. Staff told us that managers told us they provided support in managing caseloads.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service maintained good standards of infection prevention and control. Staff maintained equipment appropriately and ensured it was clean and fit for use. Cleanliness checks were in place, with ‘clean’ stickers visible and in date. Clinical areas were clean, well maintained, and suitable for delivering care, including spaces used for physical health checks and blood-borne virus testing. Staff were trained in infection prevention and control and followed safe practices, including the appropriate storage and disposal of sharps and used needles.
Environmental and equipment checks were carried out regularly, with recent audit data showing 100% compliance.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The service had systems in place to support the safe and effective management of medicines. Staff held weekly medication incident meetings to review incidents, including closed cases, and share learning.

Medicine records were accurate and up to date, with no gaps identified in prescribing or administration. Safe prescribing processes were followed, including the use of two authorised signatories for void prescriptions. A structured approach to medication management was in place, with Review and Dispensing Regimes (RDR) completed prior to Prescription Request Forms (PRF), supporting safe and consistent prescribing.

Care records showed that staff reviewed the impact of medicines on clients’ physical health in line with guidance from the National Institute for Health and Care Excellence. Individual risk assessments informed safe arrangements for medication collection and storage, including the use of lockable boxes where required. These were reviewed regularly.
The service also demonstrated safe management of naloxone, including appropriate storage, distribution, replacement, and the provision of harm minimisation advice.

Regular audits were undertaken to monitor compliance. However, a recent audit identified that Patient Group Directions (PGDs) for Hepatitis B vaccination were not in place. The service had implemented interim arrangements, and the provider’s central pharmacy team was updating the PGDs.
Overall, medicines were managed safely, with effective systems in place.
However, PGDs for Hepatitis B vaccination were not fully in place at the time of the inspection, and further work was needed to make sure they were fully applied.