CGL Drug and Alcohol Service Warwickshire

CGL Drug and Alcohol Service Warwickshire was registered with the CQC on 1 November 2022 to deliver the regulated activity: Treatment of disease, disorder or injury. It is a recovery- focused service with a full range of treatments and interventions designed to support people to take control of their recovery journey and achieve their recovery goals.

At the time of the inspection, the service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We assessed CGL Drug and Alcohol Service Warwickshire on-site 8 and 9 October 2025 with remote inspection activity until 11 November 2025. This service has not been inspected previously since it separated from a nearby service. We inspected it due to emerging risk. The concerns identified were from April 2024 to April 2025 and related to follow up support after detoxes, lack of mental health support and poor record keeping. The registered manager provided assurances of risk at an engagement meeting with the Care Quality Commission in June 2025. This is the first inspection of the service.

Our inspection team comprised of 2 CQC Inspectors, 1 Bank Inspector, 1 Senior Specialist,1 Medicines Inspector, 1 Specialist Advisor and 1 Expert by Experience (remote).

We reviewed information that we held about the provider, asked a range of other organisations for information and sought feedback from clients.

The service’s main location is in Leamington Spa and it has 2 hub location sites in Rugby and Nuneaton. During the inspection, we visited the following locations:

Leamington Spa hub
Rugby hub

During the assessment, the inspection team:

• spoke with 23 clients who were using the service
• spoke with the deputy services manager and the registered manager, who is also the service manager
• spoke with 22 other staff members including recovery co-ordinators, nurse prescribers, the partnership manager, volunteers, team leaders, individual placement support staff and quality leads
• looked at 12 care and treatment records of clients
• carried out a specific check of the medication management
• observed a Nurse Alcohol Assessment (NAA) and a referral triage assessment
• looked at a range of policies, procedures and other documents relating to the running of the service.

This was an unannounced inspection. At this inspection we assessed 34 quality statements across all 5 key questions (Safe, Effective, Caring, Responsive and Well Led). We rated the service as Good because:

• The service had a strong culture of safety, based on openness and honesty. Staff knew how to report incidents and learning was shared with staff at flash and team meetings. All staff we spoke with were open, transparent and fully committed to reporting incidents and near misses.

• Staff worked collaboratively to ensure a holistic team approach to assessing, planning and delivering care and treatment to people who use services.
• The service had effective referral and admission processes in place. Staff were proactive in raising awareness about its services to ensure people within the area could access treatment.

• The service was very proactive in the recruitment of volunteers and some who had already used its services.

• The service had a robust model in place to deliver evidenced based care and treatment. Staff and volunteers had the required skills, competence and knowledge to deliver high quality care. They were also supported to develop new skills and share best practice across the hubs.

• Recovery plans ensured clients’ needs were assessed, personalised, holistic and recovery orientated.

• Feedback from people who used the service, key stakeholders and partnerships spoke positively about the way staff treated people. People told us staff treated them with respect, kindness, compassion and dignity.

• All people we spoke with spoke highly of the service and its staff. They said it is brilliant, life-changing, encouraging and staff are always well mannered, supportive and make them feel comfortable.

• Staff and leaders had close links with external agencies, partners and communities and key stakeholders to support care provision, service development and joined up care.

• In Rugby the service extended to the first floor and refurbished this into a recovery hub for its clients and the community. The launch event took place in June 2025 with the Rugby MP (Member of Parliament) and the Lord Mayor in attendance.

• There were innovative approaches to support a person-centred pathway of care that involved other organisations to meet people’s needs. Such as an Intuitive Thinking Skills (ITS) peer led approach to skill development. They run courses for clients to gain a qualification to support access to employment and volunteering or work opportunities. The IPS (Individual Placement Support Service) had done really well in involving the service to support clients into placement for work opportunities.

• The service had enough nursing and medical staff, who knew the clients well and received appropriate training to keep people safe from avoidable harm.

• Staff understood how to protect people from abuse and the service worked well with other agencies and partners. Staff had training on how to recognise and report abuse. Staff said leaders were visible and cooperative and willing to discuss any concerns or issues.

• Leaders had a very good understanding of the services they managed and their roles. Leaders spoke confidently and clearly explained how teams worked together to provide high quality care and support to clients. Leaders continued to strive for improvement and staff were responsible for delivering change. Staff were extremely positive and grateful that they worked with a strong, supportive, approachable and visible leadership team. Some staff had worked within the service for several years and spoke positively about the culture, leaders and clients they supported.

• Staff and leaders could describe and give examples of innovations and quality improvement initiatives. Such as involving clients and their carers or partners at speaker events and well-being days that included sound bath, art, music and mindfulness sessions. Another initiative was the ‘Crack Pipe Pilot’, often referred to as a Safer Inhalation Pipe Provision (SIPP) or "safer smoking kit" program, a health-based harm reduction initiative designed to provide clean smoking supplies to individuals who smoke crack cocaine. The service collaborated with the university and provided vouchers for course completion to support clients.

• During the on-site inspection at the Leamington location we observed there were infection prevention control (IPC) issues, sharps bins not dated, naloxone and thiamine kept in an unlocked cupboard, cleanliness issues in the drug testing rooms and environmental concerns. All of these concerns and the environmental concerns were raised with the registered manager on day 1 who accepted and responded immediately to rectify the issues. The registered manager confirmed when actions were completed to resolve the issues.

• We observed a security concern for both staff and clients at the Leamington location. The door leading to the 1st floor at the top of the stairs was unlocked and easily accessible to anyone entering the building. The registered manager confirmed that facilities were contacted to insert a key code access to the door at the top of the stairs to limit access. The registered manager confirmed facilities completed the task on 16 October 2025.

• We observed there were some inconsistencies in prescribing collection forms (hard copies) not being signed by staff, when clients had signed them at the Rugby location. The electronic record however was up to date. The registered manager confirmed the teams would be reminded to sign the hard copies as well as ensuring the electronic record is kept up to date.

• The service was in breach of regulation 17 in governance because governance processes did not always operate effectively, we found lack of MCA assessments recorded for ongoing monitoring, supervision and appraisal was not recorded appropriately and environmental audits didn’t identify IPC cleanliness and security concerns.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Mental Health Act responsibilities and Mental Capacity Act and Deprivation of Liberty Safeguards

We include our assessment of the provider’s compliance with the Mental Capacity Act and, where relevant, Mental Health Act in our overall inspection of the service.

We do not give a rating for Mental Capacity Act or Mental Health Act. However, we do use our findings to determine the overall rating for the service.

We raised the issue that there was lack of evidence of continuous practice and ongoing monitoring of the Mental Capacity Act recorded in care records. Staff and leaders told us this was discussed during the person’s initial assessment, kept up to date with the training and understood how and when to assess whether a client had the capacity to make decisions about their care. Electronic records notes and policies were reviewed.

Further information about findings in relation to the Mental Capacity Act and Mental Health Act can be found later in this report.