CGL Drug and Alcohol Service Warwickshire

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 as Good. This meant people were safe and protected from avoidable harm.

The service was safe, mostly 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 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 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 service had a strong 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 learnt to continually identify and embed good practices. Staff told us there is an open and positive culture between staff clients and the leadership team. Staff told us there is transparency and information was given to them when asked. They were actively listened to, and changes were made following incidents.

We scored the service as 3. The evidence showed a good standard of care. 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 no serious incidents reported in the last 12 months
• All staff knew what incidents to report and how to report them. We reviewed the incident reporting policy and all staff we spoke with knew how to report and address any issues or concerns.
• Staff reported all incidents that they should report. This was evidenced in incident review group meeting minutes from the last 3 months. Actions and learning from incidents were identified and improvements reflected.
• Staff understood the duty of candour. They were open and transparent and gave clients and families a full explanation if and when things went wrong.
• Staff received feedback from investigation of incidents, both internal and external to the service. Team managers shared incidents sensitively but effectively and learning during flash meetings and highlighted areas needed for improvement or training.
• Staff met to discuss that feedback during monthly incident panel meetings and daily meetings with staff. Staff told us managers would ask how best learning could be shared to support them.
• There was evidence that changes had been made as a result of feedback. We reviewed minutes of group meetings with evidence of changes made and also actions following the on-site inspection to ensure safety to staff and its clients.
• Staff were debriefed and received support after a serious incident.

The service continually worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was always managed, monitored and assured. The service had a good clinical model which was robust and its referral and admission processes ensured that all relevant information about the clients was thorough to meet client’s needs safely.

We scored the service as 3. The evidence showed a good standard of care. 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. Clients said they didn’t feel alone in managing their care journey. Staff told us the collaboration and information sharing between professionals such as the probation service, MARAC (Multi-Agency Risk Assessment Conference) and the Integrated Offender Management teams created a supportive environment. Clients told us they felt safe when coming to the service. The service ensured prison leavers were assessed within 3 weeks of leaving prison and for continuity of care Warwickshire performed 62% above the national average of 57%).The service had a KPI (key performance indicator) to make contact with people that had been referred to the service within 5 working days and completed a triage within 14 days of the referral.

• The service’s referral and admission processes ensured that all essential information about the client was received to determine if the client’s needs could safely be met. Care records showed information about the clients prior to commencing treatment and the Entry into Service assessment including comprehensive details of contact calls records and the assessment.

• Staff involved all the necessary healthcare and social care services to ensure clients had continuity of safe care, both within the service and post-discharge. Each client was allocated a recovery worker and a nurse prescriber. Staff offered clients a physical health care assessment to understand their physical health needs and made referrals to the mental health services on admission if necessary.

The service worked with people to understand what being safe means to them as well as with their partners on the best way to achieve this. The service concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and made sure they shared concerns quickly and appropriately. The service worked closely with multi-agency risk assessment centres to share information and protect victims of domestic abuse by ensuring the safety of clients. Staff completed domestic abuse training and could contact the safeguarding lead for any questions.

We scored the service as 3. The evidence showed a good standard of care. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The service 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. Clients told us they felt safe and supported by staff and were able to engage in the process of their care and treatment as well as raise any concerns.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. There was a safeguarding policy in place both for adults and children and young people which up to date.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff attended regular meetings to discuss important information about safety and lessons learnt. There were weekly and monthly multidisciplinary team meetings to discuss safeguarding and there were also designated safeguarding leads that staff or clients could go to ask any questions.

There was a multi-agency approach to safeguarding. Staff told us they worked closely with the safeguarding lead and shared information that showed changes in behaviour and highlighted concerns to ensure clients and staff were safe. We saw evidence of multidisciplinary involvement for assessments of clients in care records.

Although there were no current active safeguarding referrals, in the past 3 months there had been 10 safeguarding referrals across the 3 hubs in total. There were effective systems and processes in place to ensure clients were protected from abuse and neglect.

• Staff could give examples of how to protect clients from harassment and discrimination, including those with protected characteristics under the Equality Act.

There were thorough records in place that staff reviewed at weekly and monthly leadership team meetings. Staff told us they knew how to make a referral and ensured the Safeguarding Lead was made aware too. Referrals were reviewed by the area managers, team leaders, clinical leads and the compliance team with a record of the referral, actions taken and progress.

Mental Capacity Act

Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards. Staff took all practical steps to enable clients to make their own decisions. When clients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

The service had arrangements to monitor adherence to the Mental Capacity Act; however, there was lack of evidence of ongoing monitoring of the Mental Capacity Act recorded in care records. Staff and leaders told us this was discussed during Entry into Service 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. The service had a lead nurse for the oversight of the Mental Capacity Act who had a more in-depth better understanding of MCA.

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.

The service used recognised ratings scales to record the severity of dependence and clients’ conditions, care and treatment outcomes. The service carried out comprehensive alcohol and health assessments and ensured a withdrawal assessment was completed to provide the necessary care and treatment or referrals where required. Recovery plans were personalised with details of medicines, goals and care and treatment for each client.

We scored the service as 3. The evidence showed a good standard care. 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.

Clients told us they were involved in discussions around managing risks. Meetings with clients and their families were held every 4-6 weeks and service user plans were completed. We saw evidence of 2 clinical multidisciplinary team meetings with client interaction and involvement recorded in the discussions.

We reviewed 12 care records during the inspection and most of which showed clients involvement in recovery planning and risk assessments. Staff completed risk assessments for each client on admission using a recognised tool and reviewed this regularly and if there was any incident.
Staff involved clients in care planning and risk assessments and could participate in MDT’s (multi-disciplinary team) reviews.

Staff communicated with clients so that they understood their care and treatment, including finding effective ways to communicate with clients with communication difficulties. Staff had access to Naloxone (Naloxone is a medicine usually in the form of a nasal spray that rapidly reverses an opioid). We saw evidence of Naloxone supplies discussed at flash meetings to ensure adequate stock levels.
Staff enabled clients to give feedback on the service they received via surveys or community meetings. Staff ensured that clients could access advocacy.

We observed 2 telephone triages and noticed staff conducted these very well with warmth and compassion. Staff ensured there was a focus on obtaining the necessary information and offering health advice.

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 at the Leamington location. They did not always make sure equipment and facilities supported the delivery of safe care at the Leamington location. However, technology did support the delivery of safe care at both locations in Leamington and Rugby.

We observed cleanliness issues in the drug testing rooms and environmental concerns at the Leamington hub. There were stains on the side desk where clients sit, paper towels on the floor, build-up of dust, cobwebs and build-up of dirt in the kitchen on the first floor. We received confirmation that a deep clean was to be carried out for the whole of the premises.

We observed a security concern for both staff and clients at the Leamington location. The door leading to the first floor at the top of the stairs was unlocked and easily accessible to anyone entering the building. Staff and clients would be subjected to significant privacy concerns and potential threats to personal safety if unauthorised individuals manage to enter the upper-level hallways or stairwells. 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. This was completed on 16 October 2025 following our onsite visit. These concerns and the environmental concerns such as the radiator and door stopper falling off the wall and broken hand dispenser, were raised with the registered manager who accepted and responded back to take immediate action to rectify the issues. The registered manager confirmed completed actions to resolve the issues.

The concerns related to the environment were at one location only and not service wide. The Registered Manager provided information to rectify the issues and plans were in place to prevent the issues from reoccurring.

Staff did regular risk assessments of the care environment. We saw evidence of the annual health and safety audit dated 14 and 15 October 2024, the registered manager confirmed the next annual audit was due in October 2025. We reviewed examples of fridge temperature checks and the clinical environmental checks as part of the inspection. These had all been completed.

We reviewed 2 clinic rooms and found these were fully equipped with accessible resuscitation equipment and emergency drugs. The equipment had been checked within the appropriate timescales.

The service had enough suitable equipment to help them to safely care for the clients and there were adequate supplies of vaccines, thermometers, blood pressure monitors and sufficient space to store these. The service used a waste removal company to dispose of clinical and non-clinical waste.

We saw a trolley holding thiamine and naloxone in an unlocked cupboard, we found alcohol wipes passed their expiry date and an expired box of face masks at the Leamington location, the sharps bin wasn’t dated, we also observed exposed cotton wool, testing equipment and a sharps bin in the rear consultation room in Leamington. The unlocked trolley was then locked and thiamine was removed also reminding staff of the expiry dates. The alcohol wipes and face masks were removed by day 2 and all other out of date equipment was checked and replaced where necessary. The sharps bin was dated on the same day. Following feedback from our inspection, the registered manager confirmed the cotton wool, equipment and sharps bin had been removed and staff were reminded that only rooms with suitable flooring were to be used for any testing. These issues were also going to be addressed at the flash meetings.

We observed no issues with cleanliness and the environment at the Rugby location. All client areas, reception and the meeting rooms were clean and well-maintained. It was a very warm, welcoming and spacious environment.

We scored the service as 3. The evidence showed a good standard of care. The service made sure there were always 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.

Managers had calculated and reviewed the number of recovery workers needed for each shift in accordance with national guidance. Each recovery worker was allocated a caseload of clients.

Caseloads were managed via the electronic management system including how sickness was managed. Although caseloads varied and there was no set caseload, we saw evidence of caseloads by each hub; Leamington there was 626, Nuneaton 628 and Rugby 274 as of 14 October 2025. For those in structured treatment; Leamington there were 564, Nuneaton 569 and Rugby there 255. Leaders told us reports were produced from the management system to retrieve data about caseloads. Local managers worked closely with their teams to look at the numbers on caseloads. Staff were supported through case management supervision to identify clients that were ready to be supported to move to the next stage of their treatment (e.g. recovery support) to maintain a steady flow of clients moving through treatment.

Staff told us there had been a lot of movement with key workers that disappointed some of their clients. Key workers were holding onto a lot of workloads but there was a big drive in recruitment that helped. When people move around within the service and are promoted this would leave a gap, which is eventually filled.

If staff were absent or there were vacancies, the service followed the staff absence process to determine the need for agency staff, ask part time staff if they would like additional hours in an interim period, or utilise sessional workers or volunteers (dependent on the role). In the past 3 months the service utilised agency recovery coordinators across all sites and they remained with them whilst the recruitment of new staff were inducted. The service still had 2 agency staff in Leamington, 1 in Rugby and 1 in Nuneaton.

Staff turnover in the past 12 months was 12.5% in Nuneaton, 8% in Rugby and 19.7% in Leamington. There were varying reasons for staff leaving such as taking retirement, health issues or if the job was not what they wanted. Staff vacancies and recruitment were discussed at various meetings such as Performance and Quality team meetings. Staff turnover across the service in the past 3 months was 3%.

Sickness in the past 12 months was 6.16% in Nuneaton, 2.62% in Rugby and 5.67% in Leamington. Managers monitored sickness at weekly managers’ meetings and daily flash meetings. We reviewed the minutes of flash meetings. Staff sickness in the past 3 months across the service averaged 4.3%.

Managers regularly reviewed and adjusted staffing levels and skill mix. The current vacancies were very low across all the sites. There were 3.5 vacancies across the service.

There were 7 volunteers at the service, including 2 in Nuneaton, 2 in Rugby and 3 in Leamington.

Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the client group using the service. Bank and agency staff were given a full induction.

The service delivered mandatory and non-mandatory training, some of which was provided by external partners. Examples of training included safeguarding adults and children at risk, learning disabilities and autism. Staff told us they received mental health and physical health awareness, understood detox, naloxone and trauma informed approaches to support clients.

As well as the mandatory training above, the service also offered a suite of over 450 online and face to face training courses available to staff. These were available to all paid and non-paid staff and they could all access these on the provider’s online system.

Training compliance for the mandatory training over the past 3 months was 96.22% in July 2025, 96.5% in August 2025 and 97.33% in September 2025.

• Supervision for the past 3 months was 73%. Staff were required to have a minimum of 4 per year. There was lack of evidence to show if supervision and appraisals were recorded appropriately.

Managers provided new staff with appropriate induction. Managers provided staff with supervision (meetings to discuss case management, to reflect on and learn from practice, and for personal support and professional development) and appraisal of their work performance. Managers ensured that staff had access to regular team meetings.

The appraisal review rate in the last 12 months was 47.54%. This was the overall rate across all hubs for CGL Warwickshire.

Supervision for the past 3 months was 73%. Staff were required to have a minimum of 4 per year. However, all staff we spoke with had regular supervision and open conversations with their managers daily. Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. Managers ensured that staff received the necessary specialist training for their roles. Managers dealt with poor staff performance promptly and effectively.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

During the on-site inspection at the Leamington location, we observed there were infection prevention control (IPC) issues, sharps bins not dated. The sharps bin wasn’t dated so this was dated on the same day. We observed exposed cotton wool, testing equipment and a sharps bin in the rear consultation room in Leamington. The registered manager confirmed the cotton wool, equipment and sharps bin had been removed and staff were reminded that only rooms with suitable flooring were to be used for any testing. These issues were also going to be addressed at the flash meetings.

We observed no issues with cleanliness and the environment at the Rugby location. This was well maintained and kept clean. The registered manager was going to consider using ‘clean’ stickers for visibility. There was lack of evidence to show cleanliness in drug testing rooms across both sites.

Staff completed regular environmental and infection prevention and control audits and where areas of improvements had been identified, appropriate action plans were in place.

Cleaning records were up to date and demonstrated that the areas were cleaned regularly. We received confirmation that a deep clean was to be carried out for the whole of the premises in Leamington.

We scored the service as 3. The evidence showed a good standard of care. 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 mostly followed good systems and processes to prescribe and administer medicines safely. Staff followed good practice in medicines, dispensing, administration, medicines reconciliation, recording and disposal in line with national guidance. However, storage management was not always good. We observed naloxone and thiamine were kept in an unlocked cupboard. The registered manager ensured the unlocked trolley was locked and thiamine was removed also reminding staff of the expiry dates.

Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did it in line with national guidance.

Staff followed systems and processes to prescribe and administer medicines safely. Staff we spoke with knew where to access relevant guidelines including BNF, NICE, and Drug Misuse and Clinical Dependence: UK guidelines on Clinical Management. There were relevant medicines management policies in place which were comprehensive and reviewed regularly.

Staff reviewed the effects of medication on clients’ physical health regularly and in line with NICE guidance.

Clients told us staff reviewed their medicines regularly and provided advice to them about these. Care records showed that staff recorded ongoing discussions with clients about the nature, purpose and potential side effects of their medicines.

Clients had self-testing kits so that they could test before using a drug. This was counselled on harm reduction. Some clients collected their medicines from the pharmacy. Records for the delivery and dispensing of medicines were complete and up to date electronically, however there were some inconsistencies in prescribing collection forms unsigned by staff. The registered manager ensured that both records were kept up to date and a reminder was to be sent out to all staff.

All staff were trained to use Naloxone and nurses supported other agencies who stocked these medicines around how to safely administer this in emergencies. The service’s electronic recording management system recorded when clients were trained in how to use Naloxone and staff signed this on the system.

Leaders told us how the service assess a client’s suitability to collect their prescription and keep substitute medicine at home. Risks were assessed and regularly reviewed by staff. Clinical governance meetings evidenced the review of OST (Opioid Substitution Treatment; to help people safely stop using highly addictive drugs like heroin or prescription painkillers) and where prescribed medicine was supervised consumption or unsupervised. Changes to medicines depended on individual circumstances. For example, if the client was street homeless, this would go straight to the medical staff and prescriptions would be reviewed instantly.

We saw evidence of good multidisciplinary teamworking between Staff nurses, pharmacists, leaders and clients. Staff supported clients to collect their medicines from hospital for them. Prescriptions were issued in a timely manner with good processes and staff checked doses to make sure they were correct.

There was good record keeping with prescriptions as the folder was locked away and only an authorised list of people could access these. We observed an audit trail of collected prescriptions on paper; these would then be scanned into the electronic management system. There was a weekly audit process to ensure prescriptions were checked and if they were not collected, this was flagged to the key worker and all the management team.