CGL Sefton

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first inspection of this service. This key question has been rated as good.

This means the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes operated effectively. Performance and risk were managed well. Staff collected and analysed data about outcomes and performance. They used this to identify improvements. There was a culture that supported ongoing improvement and service development

We have not awarded this service a score for Well-led.

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

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Change, Grow, Live had a mission statement, and vision and values in place that filtered down to the service. The organisation’s identified mission statement was to “to transform lives by providing services built on evidence and compassion, rooted in the communities we serve”. This was supported by an identified vision of “a world where people are seen for their potential not judged for their problems” and underpinned by the values of “being open, bold and compassionate”.

Staff we spoke with were generally aware of the provider’s vision and values. The values formed part of the recruitment process and interview format. Supervision sessions and appraisals were values led.

Staff had the opportunity to contribute to discussions about the strategy for the service, including when the service was changing. Consultation events had been held as part of the process which introduced a pathway specific staffing structure in the service to replace the previous generic model. The service had a three-year strategy and development plan in place that had been developed by the service management in consultation with staff and stakeholders. The Bootle service had also consulted with staff over the proposed opening of a new building alongside the existing premises.

The provider had introduced a 5-year organisational strategy in 2025 which included staff feedback and consultation. They had completed show and share sessions as part of this process and staff were able to sign up to individual projects identified within that strategy to get regular updates and the opportunity to input.

Staff we spoke with felt respected, supported and valued. They spoke positively about the provider organisation and local managers. Staff were proud of the organisation as a place to work and generally spoke positively of the culture.

Staff teams worked well together. There was strong collaboration, team-working and support. Staff spoke positively about their colleagues and the local team. They described collaborative team working and a supportive environment. There were good relationships with managers and senior staff within the teams.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the skills, knowledge, and experience to perform their roles and provided effective clinical leadership to staff. They demonstrated a good understanding of the services they managed and were able to describe how teams worked together and collaborated with external providers to deliver high-quality care. They understood the challenges the service faced and were able to outline short, medium and long-term plans to address these concerns. They had a goodunderstanding of the client base and the experience to perform their roles.

Leaders were visible within the service and approachable to both staff and clients. Staff we spoke with knew who senior managers were and understood their roles. Managers were described as open and approachable. Staff we spoke with told us managers were supportive and open to challenge.

Leaders had access to specialised training and development programmes. This included training around recruitment, supervision, problem solving and absence management. Staff not currently in management roles could access development opportunities. The provider operated a 2-day leadership training programme. A member of staff in Bootle was completing THRIVE leadership training.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had policies and procedures in place to support whistleblowing and staff members’ freedom to speak up. Staff we spoke with knew how to access the policy and told us they would feel confident raising any concern they may have without fear of reprisal. They told us that managers were open and approachable and described an open and honest culture.

The whistleblowing policy included details of external organisations that staff members could raise concerns with if they felt they could not raise them internally within the service or company.

In the 12 months prior to our inspection (1 May 2025 until 30 April 2026) the service had not received any formal freedom to speak up concerns. However, managers were able to discuss incidents where concerns had been raised without triggering a formal process, for example around staff attitude or boundaries and explain how these were addressed and resolved.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service promoted equality, diversity and inclusion within the workplace. The provider offered a range of supportive forums and safe spaces and operated an Inclusion Champions network group which promoted inclusion and equality by supporting positive change. Staff had access to national forums operated by the provider including an accessibility forum, an LGBTQ+ forum, a race equality forum, a trans and non-binary forum, a menopause group and a veterans’ forum. Forums met monthly and offered peer support as well as promoting education and organisational change to deliver more inclusive environments. At a service level there were local champions in place including an LGBTQ+ champion and a menopause champion. They linked in with national champions and forums and provided local support to staff in the Sefton service.

The service employed a number of neuro-diverse staff and had undertaken work to support them in the workplace. This included workplace adaptations. For example, staff who required them were offered noise cancelling headphones and quieter workspaces away from large staff offices. Managers built additional breaks into meetings and training sessions, and some staff had apps on their work phones that were designed to support neuro-diverse individuals. Senior staff and team managers had received training in how to effectively support neurodiverse staff in the workplace.

In addition to adaptations for neuro-diverse staff the service had implemented other reasonable adjustments for staff including specialist chairs, footstools, desks and computer software. The provider had a Reasonable Adjustments Policy and process to support managers in responding to need.

Staff were able to apply to work flexibly to accommodate personal circumstances, such as caring responsibilities and health needs. We spoke with staff who worked flexibly for these reasons. They told us that managers had been sympathetic to their needs and worked collaboratively with them to identify effective work patterns. The provider had a Flexible Working Policy and process to support managers in responding to requests for flexible hours.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

There were effective governance structures and processes in place at location, service and provider level. Our findings from other key questions demonstrated that governance processes operated well.

There were processes in place to monitor the safety and quality of premises, equipment and the delivery of care and treatment. Assurance processes included audit, performance monitoring, the review and investigation of incidents and complaints and the analysis of feedback from staff, clients and stakeholders.

Staff completed both clinical and non-clinical audits which provided appropriate assurance. Staff acted upon the results of audits when required. Audit and quality assurance processes had identified issues with the services record structure and documentation. The service was developing and introducing new documentation to address this. The service ensured that incidents and complaints were properly reviewed and investigated by staff trained to do so. Staff worked collaboratively with external agencies to review client deaths and had implemented recommendations from the reviews of deaths, incidents, complaints and safeguarding.

The service held a monthly integrated governance meeting which reviewed performance, managed the service’s governance processes and ensured that learning from incidents, complaints and audits was identified and disseminated. Staff meetings including daily flash meetings and monthly team meetings had standard agendas which ensured that essential information and learning was shared with staff.

The service had key performance indicators (KPIs) in place covering areas such as numbers in treatment, client retention, outcomes and detoxification referrals. The service was performing well against KPIs. Performance was captured in quarterly Performance Management Frameworks submitted to commissioners and discussed in the service’s Integrated Governance Meetings.

The service had a local risk register. Staff were able to raise issues for inclusion on the risk register. Risks rated as high on the service risk register were also escalated to the provider level risk register. Staff concerns matched those on the risk register. Managers we spoke with demonstrated a good understanding of the risks the service faced and could describe actions in place to mitigate them.

Business continuity plans were in place and provided guidance for staff in emergency situations, including adverse weather, the loss of premises or IT systems and public health emergencies.

Staff understood the arrangements for working with other teams, both within the provider and externally. The service submitted data and appropriate notifications to external bodies when required.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service demonstrated a clear understanding of its responsibility to work in partnership with other agencies to deliver coordinated care. Staff and leaders collaborated effectively with a wide range of external stakeholders, such as commissioners, service delivery partners, statutory agencies, voluntary and community organisations. Information and learning were consistently shared with a range of partners, including hospitals, GPs, probation services, and mental health services. External stakeholders we spoke with told us that the service had worked to establish positive partnerships within the local health system and develop care pathways that benefitted clients and improved care.

The service employed an Asset Based Community Development lead who worked to develop partnerships within the community and with other service providers and recovery agencies. In addition, the service employed a Community Educator. They engaged with community groups and services such as pharmacies, hostels, probation, social workers, community nurses and the Police. They provided training around drug and alcohol awareness and promoted the service and the help available.

In the weeks prior to our inspection a contaminated batch of drugs had been identified in the Sefton area. The contaminated drugs had caused overdoses within the community. The service had worked proactively and effectively with partner agencies and other services to coordinate a response. This included raising awareness and providing naloxone kits and training to hostels, the fire service and other agencies that may encounter people at risk. The outreach team worked with homeless people and homeless services. External stakeholders we spoke with told us that the service’s response had been instrumental in minimising harm and further deaths. The response was based on a multi-agency response plan that was in place which the service had been instrumental in developing alongside commissioners and partner agencies.

The service maintained strong links with partner agencies and third sector organisations to support joined-up care and improve access and engagement for clients. Leaders demonstrated active engagement with stakeholders through regular meetings and forums, including the local Combating Drugs Partnership, local safeguarding partnerships for both adults and children, the Sefton Health Protection Forum and the Sefton Homelessness Forum.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The service demonstrated a commitment to learning, innovation and improving outcomes for clients both within the service and across the local system. Staff described a positive learning culture and told us they were given the time and support to discuss and implement opportunities for improvement.

Staff and external stakeholders described how the service had evolved and improved since it took over the contract for Sefton. Access and the number of clients in treatment had increased through the development of outreach programmes and the introduction of processes such as open access, duty rotas and the provision of same day appointments and prescribing. They described an ongoing programme of improvement in areas such as group provision, staff skill mix and partnership working.

The service participated in research projects. For example, the service had been part of a research project ran by a local university to understand the needs of street drinkers in the area.