CGL Sefton

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 inspection for this service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

The service was safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to clients and themselves well.

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, the record structure and documentation in place did not explicitly capture a risk management plan. This meant that risk information was not always quickly accessible to staff who may be unfamiliar with the system. The service had identified this concern and were introducing new functions on the system and new documentation to address this.

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 learnt to continually identify and embed good practice.

Staff we spoke with knew what incidents to report and how to report them. Staff used an electronic system to report incidents. Staff we spoke with were aware of the provider’s adverse incident policies and were able to discuss the type of incidents they would report. Staff reported incidents such as prescribing or medication errors, data breaches, incidents of violence and aggression and safeguarding concerns. Reported incidents were reviewed by managers and senior staff within the service. Trends and themes in incidents were identified and monitored through governance processes and discussed in monthly governance meetings.

In the 12 months prior to our inspection (1 May 2025 until 30 April 2026) the service reported 197 incidents. Incidents covered a range of incident categories including prescribing and medication, data breaches, acts or threats of violence and aggression, safeguarding and client deaths.

Managers debriefed and supported staff after any serious incident. Staff we spoke with told us they had been supported following incidents. Staff could access additional support from the provider’s employee assistance programme.

Managers investigated incidents thoroughly. Clients and their families were involved in these investigations. Managers flagged incidents for investigation during the incident review process and allocated a staff member to lead the investigation. Staff carrying out incident investigations had received training to support them in the role. All client deaths were subject to a treatment care review. Treatment care reviews were discussed and signed off in dedicated meetings held twice a week. The service worked with partner agencies to review incidents where appropriate and contributed to local death and mortality reviews.

Learning from incidents was discussed in monthly integrated governance meetings and disseminated to staff. Staff received feedback from investigation of incidents, both internal and external to the service. Staff received feedback in daily flash meetings, monthly team meetings and through formats such as emails. Where appropriate, individual learning was discussed in supervision sessions. Staff met to discuss the feedback and look at improvements to client care.

There was evidence that changes had been made as a result of incident reviews. For example, following an increase in deaths amongst service users recently discharged from hospital, the hospital in-reach team was increased from 1 to 2 workers, and work was undertaken to improve contact and engagement with service users on an end of life pathway. Other examples included refreshing the process to check the service had the correct information and details of service users and changes to the on-site lone working policy.

The service implemented duty of candour when required. Staff understood the principles and process behind duty of candour and had access to a provider level policy for guidance. Staff were open and transparent and gave clients and families a full explanation if and when things went wrong.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service worked well with external services and organisations to establish and maintain safe systems and care pathways. They worked with partner agencies to provide easy referral into the service, joined up working during treatment and safe discharge post treatment.

Referrals were accepted from a range of sources and organisations, including self-referrals, GP services, local authorities, hospitals, mental health services and the Police and criminal justice system. The service had a dedicated assessment team who triaged, and where required, prioritised referrals.

People referred into the service could either attend drop-in clinics or were offered appointments by the assessment team to begin their treatment journey. The referral, triage and first appointment processes for the service ensured that all essential information about the client was received in order to determine if their needs could be safely met. This included accessing GP summaries and safeguarding records, as well as conducting initial drug screening. Referrals deemed as urgent could be seen on the same day. A duty system meant that new clients, or clients returning to treatment, could see a nurse for physical health concerns and a non-medical prescriber to begin opiate substitution therapy on the same day, if this was required.

The service provided different care pathways to clients dependent on their need. These included opiate, non-opiate and alcohol pathways provided by dedicated teams as well as a criminal justice pathway for clients on drug or alcohol rehabilitation requirement orders. Where required these teams worked together to offer safe care to clients with complex needs and co-dependence.

The service worked well with partner agencies to safely support clients through their treatment pathway. The service liaised effectively with other healthcare providers, engaged with clients and facilitated transition between services. This included hospital liaison workers in the event that a client was hospitalised and links with dual diagnosis workers from the local mental health NHS trust to support clients with co-morbid mental health concerns. Dual diagnosis workers attended both locations weekly. The criminal justice liaison team worked closely with probation and services to support clients transitioning from prison or whose sentences included an alcohol treatment requirement or a drug rehabilitation requirement.

The service had shared care arrangements in place for clients prescribed by their GP. There were shared care protocols and a shared care recovery worker in the Bootle service who worked as liaison between the service and local GPs signed up to the protocol. The number of clients under shared care was low, due in part to the retirement of GPs who had previously provided shared care and low uptake amongst newer GPs. However, the service was working to increase the number of GPs involved.

The service offered pathways into residential detoxification and rehabilitation services. There were good links with local and regional providers and referral pathways in place. The service worked with the local social care authority to fund these placements.

The service provided a range of onward referrals and signposting for clients ready for discharge. These included mutual aid groups, community support services and third sector organisations that supported recovery, abstinence and social inclusion.

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 so when appropriate. Safeguarding concerns were recorded on the incident management system and reviewed by managers. In the 12 months prior to our inspection (1 May 2025 until 30 April 2026) the service raised 19 safeguarding referrals. 7 of those related to adults and 12 were child safeguarding referrals.

Staff completed safeguarding training as part of the mandatory training programme. Across the service compliance with safeguarding adults training was 100%. Compliance with safeguarding children training was 84%.

Staff we spoke with knew how to recognise adults and children at risk or suffering harm and worked with other agencies to protect them. They knew how to make a safeguarding referral and who to inform if they had concerns. Staff could access support from identified safeguarding leads within the service and at provider level. There were safeguarding adult and safeguarding children and young people policies in place to support staff.

Safeguarding concerns were recorded on the care records system and captured in risk assessments. Safeguarding incidents were reported via the electronic incident reporting system. Safeguarding concerns and incidents were reviewed regularly by managers and safeguarding leads.

Manager and senior leaders we spoke with described positive relationships with local authorities and safeguarding boards. Teams included qualified social workers who were employed by the provider and who worked in partnership with social workers from the relevant local authorities.

Staff followed safe procedures when children or young people visited the service. Both locations offered a family room that could be used where required.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff completed risk assessments for each client when they entered the service. Client risks and risk assessments were reviewed regularly in each key worker meeting or in response to an incident or change in the client’s circumstances or risk factors.

We reviewed 8 care records during our inspection. All records had a comprehensive risk assessment in place that had been regularly reviewed. Risk assessments covered key areas including an assessment of drug or alcohol use, injection history, risk to self, risk to others and mental health.

Staff worked with clients to proactively manage identified risks. Notes on the system and key worker reviews evidenced discussion around risk management and harm minimisation. However, the record structure and documentation in place did not explicitly capture a risk management plan. This meant that risk information was not always quickly accessible to staff who may be unfamiliar with the system. We discussed this with service manager during the inspection. They confirmed that the service had identified this through their quality assurance processes, staff feedback and external reviews. In response, the service was introducing a new client overview page which gave a snapshot of client risk and were reviewing and redesigning the current documentation used in the risk assessment and risk management processes.

Staff routinely and regularly provided clients with harm minimisation advice in relation to the risks associated with their continued drug and alcohol misuse. Clients had access to harm minimisation facilities such as a needle exchange. Clients we spoke with told us that staff had regularly discussed harm minimisation with them and provided appropriate advice in their review meetings. Information on harm minimisation was visible within services in both leaflet and poster form.

Staff responded promptly to deterioration in client’s health and responded to changing risks. Staff identified these changes through regular engagement with clients, reviews of assessments and liaison with other stakeholders such as pharmacies, GPs, safeguarding authorities and other health services. Staff understood processes for responding to a deterioration in health or a change in risk. Staff had access to additional specialist teams to support this including physical health nurses, outreach workers and the family team.

Staff assessed clients’ suitability to collect their prescription and to keep their medication at home. Where children or vulnerable people were present in the home environment staff provided lockable safe storage boxes for client’s medication.

Staff followed clear processes if a client did not attend appointments or unexpectedly dropped out of treatment. This included attempting to contact the client via phone or text, liaising with other services such as dispensing pharmacies or GPs, carrying out home visits and utilising the outreach team. Key workers, team managers and medics held case discussions to review clients who had failed to attend appointments or disengaged from the service. Decisions to discharge clients who had disengaged were signed off by team managers.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service was primarily delivered from 2 premises located in Southport and Bootle. Both premises were clean, well maintained, well-furnished and fit for purpose. The reception areas at both premises offered tea and coffee making facilities as well as water dispensers. Clients were offered drinks on arrival. The reception area at the Bootle service also included client access to computers. Reception areas included information on the service and partner agencies, as well as a range of information relevant to the client base and guidance on how to provide feedback or raise a complaint.

Staff completed and regularly updated thorough risk assessments of all areas and removed or reduced any risks they identified. Staff completed appropriate daily, weekly and monthly environmental checks. Both premises had annual fire safety risk assessments in place and nominated fire wardens completed 6 monthly fire risk assessment reviews. Both premises had completed ligature risk assessments, legionnaires disease risk assessments and assessments against specific work activities such as manual handling and lone working.

All interview rooms had alarms and staff available to respond. All clinic rooms had the necessary equipment for clients to have physical examinations. Staff made sure equipment was well maintained, clean and in working order. There were records of regular checks, maintenance and cleaning of equipment. Staff completed daily checks on the temperature of fridges containing medication and vaccines.

Both locations provided needle exchange services. Staff completed an annual needle exchange risk assessment to ensure facilities were fit for purpose. Staff completed regular stock checks. There were appropriate facilities and procedures for clinical waste.

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 enough staff, and an appropriate skill mix to keep clients safe and deliver effective care. Vacancies were low and reducing with ongoing recruitment.

There was a Service Manager and Deputy Service Manager who oversaw the Sefton service, and Project Managers in place in both the Bootle and Southport teams, who were responsible for the delivery of services within each team.

Both Bootle and Southport services were structured by client pathways and had teams of Recovery Workers allocated to an opiate, non-opiate, alcohol, criminal justice, new to treatment, outreach or family pathway team. Each pathway team had a team manager who oversaw the day-to-day delivery of care within that pathway.

At the time of our inspection the Bootle service had an establishment of 32.64 wholetime equivalent Recovery Workers across the 7 pathway teams with 4 wholetime equivalent vacancies (12%). These were a 1 wholetime equivalent vacancy in both the opiate and new to treatment teams and 2 wholetime equivalent vacancies in the alcohol team. All 4 vacancies had been recruited to, and new staff were going through the onboarding process. The Bootle service also included a Group Facilitator and a Recovery Support Worker.

In the Southport service there was an establishment of 15.4 wholetime equivalent Recovery Workers across the 7 pathway teams with 2 wholetime equivalent vacancies (13%). These was a 1 wholetime equivalent vacancy in the opiate and 1 wholetime equivalent vacancy in the non-opiate team. Both vacancies had been recruited to. The new opiate worker was due to start the month after our inspection and the new non-opiate worker was awaiting pre-employment checks. The Southport service also included a Group Facilitator.

In addition to the pathway teams each service had a nurse support team. The Bootle service had an establishment of 5.4 wholetime equivalent nurses with no vacancies, and the Southport service had an establishment of 2 wholetime equivalent nurses and 1 wholetime equivalent healthcare assistant with no vacancies. There was a cohort of 6 wholetime equivalent Non-Medical Prescribers who worked across both services and who held no vacancies. There was a wholetime equivalent Clinical Lead Consultant across the service.

Both services offered a family support team. In the Bootle service the team had an establishment of 2.85 wholetime equivalents with no vacancies and in Southport the team as 1 wholetime equivalent with no vacancies.

Across both services there was also a psychology team and a Social Work team. The psychology team had 2.4 wholetime equivalent staff including a Clinical Psychologist, Practitioner Psychologist and an Assistant Psychologist. The Social Work team had an establishment of 2.8 wholetime equivalent social workers. There were no vacancies in either team.

Staff had received and were up to date with appropriate mandatory training. The mandatory training programme included courses covering basic life support and anaphylaxis, data protection and information security awareness, equality and diversity and safeguarding. Staff also completed the Oliver McGowan Mandatory Training on Learning Disability and Autism. At the time of our inspection compliance with mandatory training across the service was 94%.

Recruitment and employment processes ensured that all staff employed to work with clients had appropriate qualifications and an up-to-date Disclosure and Barring Service (DBS) certificates in place.

The service supported volunteer roles including for individuals with lived experience. There was a Volunteer and Service User Involvement Lead who oversaw the recruitment, placement and support of volunteers. Potential volunteer roles were identified in discussion with staff and managers. Volunteers had, or did, work in roles such as reception-based meet and greet roles, group facilitation support and support roles within the different pathway teams. Volunteers were subject to DBS checks and given a 2-day induction. They also completed mandatory training. Some staff had been trained in supervising volunteers, and they provided supervision and appraisal for volunteers who were in post as well as helping create development plans with them. We spoke to 1 volunteer during our inspection who had successfully applied for a permanent post within the service. They told us they had been well supported throughout their volunteering and felt it had given them the experience and confidence to apply for a permanent role.

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 managed infection prevention and control well. Both premises were clean and well maintained. Cleaning records were up to date and demonstrated that all areas were cleaned regularly. Staff adhered to infection control principles, including hand washing. They made sure equipment was well maintained, clean and in working order. There were records of regular checks, maintenance and cleaning of equipment.

All staff completed an e-learning infection control training module as part of their induction. In addition, relevant staff completed more specialist training around areas such as needle exchange, sharps and harm reduction. Staff involved in urine drug testing processes had received training on cleaning up bodily fluids and spillages. Needle exchange facilities at both premises had appropriate boxes for the safe storage and disposal of sharps and used needles.

Staff were able to access support and further guidance around infection prevention and control. Each team had an infection prevention and control champion in place. Champions completed weekly infection prevention and control checks and audits. Staff also had access to a provider level infection control policy as well as additional specialist policies covering areas such as blood borne viruses, needle stick and sharps, waste management and food hygiene.

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.

Staff followed systems and processes to prescribe and monitor the use of medicines. Medicines were primarily prescribed by non-medical prescribers within the service with support from a Clinical Lead. There were clear clinical guidelines in place outlining titration schedules and Patient Group Directions to support the non-medical prescribers in their role.

Staff reviewed prescribing regularly and provided advice to clients about their medicines. The requirement for supervised consumption and the frequency with which clients collected their medication was based on risk assessment and discussion with key workers and the client.

Staff completed medicines records accurately and kept them up-to-date. We reviewed 8 prescribing records during our inspection. Prescribing records we reviewed were completed appropriately and in line with relevant guidance. Staff reviewed the effects of each client’s medicines on their physical health according to National Institute for Health and Care Excellence guidance. Staff stored and managed all medicines and prescribing documents safely.

Staff provided clients with naloxone kits. Naloxone is a medicine used in emergency treatment to reverse the life-threatening effects of an opioid overdose. Staff trained clients on the use of naloxone before issuing the kit. The storage and issuing of naloxone was included in medicine audits.

The services had blood borne virus clinics which offered testing and vaccination. Vaccines were kept in fridges whose temperature was regularly monitored. Vaccinations stored in fridges at the time of our inspection were in date.