STARS (Southend Treatment and Recovery Service)

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

The service was safe, clean, well equipped, well furnished, well maintained and fit for purpose. Some areas of the service were untidy and disorganised, with items not stored appropriately. Additionally, the walls required repainting to improve the overall appearance. Staff assessed and managed risks to people and themselves well. Staff understood how to protect people from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed people’s safety incidents well.

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.

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.

There were systems in place for the recording of incidents and immediate actions taken to address these.

The service had a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

Staff reported serious incidents clearly and in line with policy. Staff knew what incidents to report and how to report them. Staff recorded incidents on an electronic incident reporting system and conducted investigations following each incident. Between February 2025 and January 2026, staff reported a total of 26 serious incidents. Of these, 21 involved deaths due to suspected or confirmed substance misuse, alcohol-related causes, natural causes, or other/unknown causes. There were also 2 medication-related serious incidents arising from an inability to dispense medication or other related causes, 1 incident involving antisocial behaviour and threats of violence, and 1 security-related incident. Managers completed investigations for all reported serious incidents.

The service had effective processes in place for learning from incidents and complaints which were shared with staff. Staff told us they had received feedback following safety incidents and where actions had been taken. Managers analysed and reviewed incidents for themes and trends and took action to mitigate any risks. They reviewed incidents at Governance meetings for oversight and scrutiny and cases at clinical meetings.

Learning was shared through weekly MDT meetings, which provided a supportive forum for collaborative case discussion. Staff drew on clinical and psychosocial perspectives, strengthening coordinated care planning. Discussions covered risk, decision-making, and the wider recovery journey to ensure a holistic understanding of individual needs.

Learning took place following incidents through individual and team debriefs, with shared reflections used to strengthen safety and improve practice. Minutes from governance, clinical and multidisciplinary team meetings demonstrated ongoing review of incidents, shared learning, and implemented improvements.

Protected learning time after MDT meetings ensured staff received relevant, evidence-based training. Staff also accessed wider learning opportunities with partner organisations and community networks. This supported continuous professional development and a positive learning culture.

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’s referral and admission processes ensured essential information was obtained to determine whether people’s needs could be safely met. Referrals were accepted through multiple routes, including self-presentation, GPs, mental health, social care and online submissions. Staff completed assessments promptly, carrying out an initial triage and arranging follow-up appointments where a full assessment was not immediately possible.

The service had separate teams including clinical, rough sleepers and criminal justice teams to meet differing needs. Each had separate pathways including alcohol, opiate and non-opiate pathways. The non opiate pathway was a new pathway to reach people using non-opiate substances such as ketamine, cannabis and cocaine. Staff worked in separate pathways.

The service screened referrals to check whether people met their eligibility criteria. Clients referred for residential rehabilitation and inpatient detoxification underwent an assessment to determine their suitability for consideration by the tier 4 panel, through which funding for these placements was sought. At the start of treatment people were assigned a keyworker. People assessed as high risk could access priority appointments. The service operated an open-door policy with a duty system, enabling individuals who attended on a walk-in basis to be seen wherever possible.

The organisation offered a 12-week 'Pathways to Recovery' group providing a structured psycho-educational programme. This consisted of a variety of topic areas such as increasing insight and denial, developing healthy boundaries, communication and assertiveness to relapse prevention and sustainable change planning. Additionally, the service provided an online programme called 'Recovery Online', a 12 week online structured day rehabilitation programme available for people to access anywhere in the UK. The programme supported self-employed or working professionals, parents and caregivers, housebound or disabled individuals and individuals seeking discreet care.

The service also had a protocol for non-attendance, which included attempts to contact the individual, their family or friends, liaising with GPs, mental health, probation, social services or other agencies, and requesting welfare checks where appropriate. Regular case review meetings ensured appropriate action was taken.

The 12 week Pathways to Recovery programme remains a core component of the Alcohol and Non Dependent Pathway, offering a structured and replicable psychoeducational framework.

Discharge planning was person-centred and began early, with access to a range of support options. Staff worked closely with community partners to ensure ongoing support and assisted individuals to access employment education and local college courses where appropriate.

The service had close links with Open Road who supported young people under the age of 29 with drugs and alcohol. They were based in same building and the services worked well together to support transitioning from child to adult services. The service also worked with other services and professionals such as social care, mental health, safeguarding, prisons, child centres, sexual health clinics, charities and provided employment support.

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.

The service had systems in place to protect people from harm, supported by staff safeguarding training at induction and ongoing mandatory training. Managers ensured safeguarding cases were discussed in clinical and governance meetings which enabled additional support to staff if required. The provider had a safeguarding lead, and the service had a local safeguarding lead and champions.

All staff completed mandatory safeguarding training, and at the time of inspection, compliance was 100% for an introduction to safeguarding training and 80.80% for further safeguarding training. All staff we spoke with demonstrated an understanding of how to identify and report safeguarding concerns and gave examples of how to protect people from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff gave us examples where they had raised safeguarding concerns relating to children and domestic violence.

Staff were able to recognise adults and children at risk of harm and worked effectively with partner agencies to safeguard them. The service maintained strong working relationships with external organisations and made referrals where appropriate, including to social services, the local authority and independent domestic violence advisors (IDVA). Staff attended multi-agency meetings such as strategy meetings, MARAC and child protection conferences to ensure coordinated and timely safeguarding action.

The service held regular clinical meetings where safeguarding cases were discussed. Staff were given advice about actions to take, and leaders provided support to manage complex safeguarding cases.

The service had robust systems for tracking the progress of safeguarding referrals. Safeguarding referrals were logged and discussed at clinical and governance meetings.

Staff did not routinely record their assessment of mental capacity. Where mental capacity assessments had been completed, the records were not easily accessible, as the documentation was embedded within clinicians’ notes rather than stored in a clearly identifiable or centralised location. This was fed back to the management team, who acknowledged the feedback and confirmed that they were working to improve this area.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed risk assessments and risk management plans in care and treatment records. Staff completed comprehensive initial risk assessments and updated these regularly. Staff assessed risks at the point of screening referrals and assessing people for suitability for the service. Staff completed a full risk assessment at the start of treatment. All risk assessments we reviewed included a full assessment of drug use and injection history where applicable, assessment of previous access to treatment, evidence of blood borne virus (BBV) assessments, harm reduction advice provided and assessment of motivation to change.

Staff involved people in care planning and risk assessment, with clear evidence of people’s voice in the care records. People and family members we spoke with said they felt involved in reviewing their care and treatment. For example, people were referred for support with housing and mental health, as required.

The service introduced a hospital liaison role in November 2024, carried out by a clinical member of the team to improve communication and coordination with the local hospital. This included attending A&E to identify individuals who may have required support, particularly where discharge information was not routinely shared. The role helped ensure the service was aware of people presenting to hospital, including those not previously known to the service, and supported early intervention to help prevent further risk.

Staff discussed risks to people in a range of forums. Staff shared updates about risks to and from people. Managers carried out regular audits of risk assessments, with actions and timeframes for their completion clearly documented.

The service was proactive in promoting harm reduction. Staff provided people with advice, tools, and safe equipment to reduce harm, including naloxone, a medicine used to reverse the effects of opioid use. They encouraged both people using the service and their families to carry naloxone and worked closely with local agencies to support these efforts.

Staff also collaborated with people to develop personalised crisis plans, including plans for unexpected treatment exits, ensuring coordination with other agencies when needed. If appointments were missed, staff contacted individuals to support re-engagement with the service. Staff demonstrated a strong understanding of risk management and emergency procedures. They followed clear personal safety protocols, including measures for lone working and conducted joint visits with colleagues when necessary.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff completed and regularly updated comprehensive risk assessments across the service and took action to remove or reduce any identified risks. Regular health and safety audits were undertaken, and ligature and fire risk assessments were reviewed and updated regularly.

Staff used a range of rooms and equipment to support treatment and care, including a clinic room, private rooms for one-to-one meetings, and spaces for group work and activities. Where people presented with identified risks, staff saw them in areas near the reception to ensure additional oversight.

The service was secure, with entry controlled via reception. Staff areas were restricted through coded or fob access, and access to the service was supervised. CCTV was in place in the reception and café areas. The needle exchange room was organised, tidy, and kept locked, with items stored securely. Entry was supervised, and staff had secure processes in place for the disposal of equipment.

Clinic rooms were fully equipped for physical examinations and appropriately stocked with emergency medicines, which were checked regularly by staff. However, the room was poorly organised, with equipment spread out in a way that created a potential trip hazard. Staff did not have access to resuscitation equipment. Managers were aware of this and arranged for an emergency grab bag and the necessary equipment to be ordered for use in an emergency. Following the inspection, the service provided evidence that this had been implemented.

There was no defibrillator onsite, although the service could access one locally. Managers informed us that funding had been agreed to obtain a defibrillator. All staff had access to personal alarms, and colleagues were available to respond if assistance was required.

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.

At the time of our inspection, the service was fully established except for 6 vacancies. These included 2 recovery workers, 1 recovery co-ordinator, 1 doctor, 1 criminal justice worker and 1 outreach worker. Managers were actively recruiting to fill these positions, and onboarding was already underway for some of the roles.

Managers had calculated the number and grade of nurses and recovery workers required. The number of nurses and recovery staff matched this number on all days.

The manager could adjust staffing levels daily to take account of case mix. Additional staff were sought to manage risk and support people.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. When agency and bank nursing staff were used, those staff received an induction and were familiar with the service.

Staff turnover between February 2025 and February 2026 was 8.57%. During the same period, staff sickness was recorded at 2.36% for short term sickness and 0.64% for staff on long-term sickness.

People who used the service reported that their groups or appointments mostly all took place as planned and were rarely cancelled.

Staff received and were up to date with appropriate mandatory training. The overall compliance rate for all mandatory training completion was 89.30%. The training was appropriate for the people using the service. Leaders monitored training compliance and had plans in place to ensure all staff became compliant with training courses. The service provided additional training workshops to support the development of staff.

The service provided additional training to support the development of staff. These covered different drugs, how they are used, their effects, and the risks involved, including topics like chemsex, ketamine, and nitazenes.

Staff received regular and thorough supervision. Supervision was provided on a quarterly basis but could take place more frequently. Leaders reviewed people’s pathways and recovery plans with staff working with those people, as part of supervision. They set actions which were reviewed and signed off at the next supervision. Staff spoke positively about the support they received from leaders.

Staff were given a comprehensive induction to the service to ensure they were prepared for the role. Staff completed an induction checklist to ensure they were competent to carry out their duties and identify other areas for their professional development.

Leaders supported staff to develop through yearly, constructive appraisals of their work. Staff were up to date with their appraisals at the time of the inspection and all remaining staff had their appraisal booked in for the following month.

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.

During the inspection visit, we undertook a tour of the service. We observed that parts of the environment required updating and redecoration. Although the service was clean, some areas appeared untidy and disorganised. We observed cluttered areas with items not appropriately stored, and the walls required painting and brightening to improve the overall setting.

Staff made sure cleaning records were up-to-date, and the premises were clean. Staff followed infection control policy, including handwashing. The service audited infection prevention control with compliance in all areas.

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 made sure that medicines and treatments were safe and met people's needs, capacities and preferences by enabling them to be involved in planning, including when changes happened.

There were system processes in place to safely manage medicines. Medicines were stored securely in temperature-controlled areas which were monitored. Staff knew how to escalate concerns when a temperature reading went out of range. Staff could access emergency medicines easily. Staff were trained on how to use naloxone and people who used the service were encouraged to have a supply if needed.

However, we were unable to easily locate a clear record of the administration of Buvidal (Buvidal is a long-acting, subcutaneous injectable medication used to treat opioid dependence in adults). Although administration was recorded on the service’s electronic system, there were no corresponding paper records readily available to demonstrate administration details. Managers and clinicians were aware of this issue and have since implemented a recording template specifically for the administration of Buvidal.

Controlled drugs (CD), medicines with additional storage and recording requirements, were stored and recorded appropriately.

The service had clinical administrators whose role was to oversee the correct issuing and completion of prescriptions including those people on a repeating cycle. Once a prescription was generated this was signed by an independent prescriber. Each prescription issued was logged when sent and a copy put into the person's records.

People were asked for their consent before their own GPs were contacted. Staff checked people’s medical and drug histories prior to prescribing or issuing medicines. People were offered a urine drug screen at the start of treatment and regularly during their time with the service. People were offered blood borne virus vaccinations prior to treatment for hepatitis B. HIV tests were offered by Brooks Sexual Health service who attended the site every week.

Medicines incidents were reported on an electronic system and investigated by the senior leadership team. They were also discussed at governance meetings and learning was shared with staff.