Archived: Southwark Adult Substance Misuse 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

We looked for evidence that people were protected from abuse and avoidable harm.

This key question has been rated as Good. The service demonstrated effective incident reporting, learning, and information sharing. People could access the service promptly, with no waiting lists and timely assessments, including for urgent referrals. Systems were in place to support engagement, and multidisciplinary working, with collaboration across services to maintain continuity of care. The teams included or had access to the full range of specialists required to meet the needs of clients under their care.

However, we found a breach of Regulation 12: Safe care and treatment. Mandatory training compliance was below the required standard. Compliance with BLS and anaphylaxis refresher training, and Oliver McGowan training, was low at the time of inspection. Service leaders were aware of these issues and had taken steps to mitigate risk and improve compliance. But these shortfalls reduced assurance at the time of the inspection that staff knowledge and competencies were being maintained consistently across the service

We identified a breach of Regulation 18 as workforce governance did not consistently ensure staff received consistent supervision.

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 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.

The provider had established policies and procedures for staff to report incidents, near misses, and safety events. Staff we spoke with knew what incidents to report and how to report them.

The service had established several systems and processes to share learning and best practice, this included safeguarding leads, mortality and clinical governance meetings. Managers shared learning with staff in monthly meetings and updated local training with lessons learnt.

The service worked with people and their partners to establish and maintain safe systems and continuity of care, including when people moved between different services.

There were a variety of ways in which people could be referred into the service, including self-referral through a secure online referral system, referral by other agencies or telephone referrals. People could attend a walk in appointment at various times throughout the week and receive an initial assessment on the same day. The service did not have waiting lists, those referred were offered a time and date to be assessed in a timely manner. Staff saw urgent referrals quickly and had a team whose role was to carry out initial assessments.

The service had a re-engagement policy and a newly established re-engagement team and procedure in place, which included maximising engagement with people and a procedure for re-engaging people at different stages in treatment.

Care records demonstrated multidisciplinary input into the care and treatment of individual patients. The provider carried out safety risk assessments for patients, staff, and the environment. Daily multidisciplinary team (MDT) meetings included a range of professionals who contributed to discussions and decision-making. Appropriate safety policies were in place, including safeguarding and infection prevention and control policies.

Staff adopted a multi-agency approach and worked with all relevant services to ensure continuity of safe care, both within the service and after discharge. The care and treatment records we reviewed provided evidence of consistent multidisciplinary involvement.

Feedback from stakeholders stated CGL Southwark staff consistently applied a proactive and innovative cross-sector approach to improve access to and continuity of care.

The service had safeguarding systems and processes in place to protect people from abuse and harm. Staff demonstrated an understanding of safeguarding responsibilities, supported by mandatory training compliance at 91%, and safeguarding was included in induction and ongoing training. Staff understood when to escalate concerns appropriately.

There was a designated safeguarding lead, and safeguarding was discussed in a range of forums, including MDT meetings and team meetings. Established pathways were in place to refer concerns to multi-agency forums, including MARAC (Multi-Agency Risk Assessment Conference), and MASH (Multi-Agency Safeguarding Hub).

Safeguarding considerations were discussed in MDT meetings and were reflected in risk assessments. Systems were in place to record safeguarding concerns and actions within the provider’s electronic system.

Safeguarding activity was monitored through the provider’s wider governance arrangements and internal systems. However, there was limited local oversight of safeguarding activity, and we did not see clear evidence of how themes, timeliness or assurance were routinely reviewed at service level.

The service had a designated safeguarding lead who made referrals where appropriate. Outcomes from risk assessments and safeguarding discussions may lead to referrals to multi-agency forums such as MARAC (Multi-Agency Risk Assessment Conference), TASK and Targeting Forum, or MASH (Multi-Agency Safeguarding Hub). These pathways help ensure that people at risk receive coordinated support and protection.

Staff worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. However, the quality and depth of risk assessments and risk management plans were inconsistent, and involvement of people in risk planning was variably recorded.

There were systems to assess, monitor and manage risks to patient safety. We reviewed risk assessments and risk management plans in 5 care and treatment records. Risk assessments were completed at the point of admission in all 5 out of 5 cases. However, the overall quality and depth were inconsistent, with none of the 5 assessments rated as detailed or comprehensive, and only 3 out of 5 showing evidence of updates following incidents or changes in circumstances. Risk management plans were present in 4 out of 5 cases, but the quality and actionability of these plans varied, and one case had no plan at all. Service user involvement in risk planning was fully demonstrated in 1 out of 5 cases, with the remaining 4 cases showing only partial engagement.

Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention.

Each hub had needle exchange facilities. People could access safe supplies, tests, vaccinations and treatment for blood-borne viruses (BBV) and support with sexual health. All people were routinely provided with BBV screening.

Staff discussed risks to clients in a range of forums. Evidence of risk discussions with clients was present across all case records reviewed. In the meetings we observed, staff shared updates about risks to and from clients.

Staff communicated with clients so that they understood their care and treatment. Staff had easy access to an interpreter service.

Fire risk assessments were in place, and fire drills did occur. Staff involved the necessary healthcare and social care services to support patients, where necessary.

Clinic rooms were fully equipped for people to have thorough physical examinations and staff had access to emergency drugs that staff checked regularly.

Staff carried personal alarms for emergencies. Staff followed agreed procedures to ensure their own safety during outreach visits.

Entrance to the service was secure and equipped with CCTV. This allowed staff to prepare any individual adjustments for people on arrival, if needed.

The service had secured the current location at short notice and recognised that there were some aspects that could be improved, to support staff and clients’ experience of the site. Access to all floors was via a narrow and steep staircase with uneven steps. Staff told us these created difficulties for movement between floors and could delay or limit access to rooms and meeting spaces. Four staff members raised this as a concern, describing it as a negative aspect of the working environment. The service was aware of this and had taken action to mitigate the associated risks. There was a wider piece of work ongoing to consider improvements to the environment. Several areas of the building appeared visibly worn and poorly maintained, with décor, furnishings and fixtures showing signs of deterioration. Staff and client feedback about the environment was negative.

The clinical environment was not consistently well maintained, with cluttered and disorganised workspaces across all three clinical rooms affecting accessibility and safe use of equipment. While most equipment was in date and functioning, we observed uncalibrated breathalysers in all rooms, inconsistent sharps bin management, and gaps in temperature monitoring. Stock areas were poorly organised, with some cupboards left open and corridor spaces cluttered, presenting potential risks. Overall, although basic resources were available, the environment lacked consistent organisation.

The Health and Safety risk assessment was 6 weeks out of date at the time of inspection. This reduced assurance that risks were being reviewed in line with the provider’s governance processes. The provider updated the assessment promptly once this was brought to their attention.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, training, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The multidisciplinary team included a range of specialist roles that met the needs of its client group. The team comprised recovery coordinators, doctors, nurses, non-medical prescribers, clinical psychologists, social workers, mental health practitioners, criminal justice and street outreach teams. A third of staff had lived experience. This gave staff in-depth understanding, empathy and knowledge for their roles.

At the time of inspection, there were 7 vacant posts within the service. Four of the vacant posts were in the onboarding process, with two staff due to start in October 2025. Two recovery coordinator roles were in the process of onboarding. To maintain continuity of care, existing staff had absorbed additional cases from colleagues.

There was sufficient medical cover, with clinical staff always available on site. People said they could speak with a prescriber when needed. Clinical staff had protected diary slots for walk-ins.

The clinical lead, who was a consultant psychiatrist, was accessible to staff and people and oversaw the more complex cases.

The provider carried out staff checks at the time of recruitment. Disclosure and Barring Service (DBS) checks were undertaken where required. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.

Staff participated in regular training which included Introduction to Health and Safety (98%-100% compliance), Mental Capacity Act (MCA) and DoLS (98%-100% compliance), and Equality, Diversity and Inclusion (96%-100% compliance), where compliance rates were high. However, compliance with some mandatory training was below expected levels. At the time of inspection, 40% of staff had completed required refresher training in Basic Life Support (BLS) and anaphylaxis, 23% had completed Oliver McGowan training, and 0% had completed Oliver McGowan Learning Disability and Autism training. Service leaders were aware of these training gaps through governance processes and had identified actions to improve compliance. The provider demonstrated that appropriately trained staff were available across teams during the services operational hours, and that arrangements were in place to maintain support through multidisciplinary working. However, low compliance with mandatory and specialist training reduced assurance that staff knowledge and competencies were being maintained consistently across the workforce in line with provider requirements. Following the inspection, the provider took action to improve compliance and demonstrated significant improvement in training completion rates (refresher BLS and anaphylaxis training at 89% compliance and Oliver McGowan training compliance at 100%).

Staff received annual appraisals. The appraisal yearly completion rate was 87%. We reviewed supervision compliance for 1:1 reviews. Performance was strong at the start of the year, with compliance peaking in February (90%) and March (91%), demonstrating effective oversight during this period. From April onward, results showed increasing variability, with notable reductions in May (67%) and July (70%). By August 2025, the year-to-date average compliance rate for January to August was 59%, indicating reduced consistency in maintaining supervision standards over the reporting period. Staff expressed a strong desire for regular reflective practice sessions to support wellbeing and professional development. We found an instance where one member of staff with an active caseload had not received supervision. Records showed that new staff did receive comprehensive inductions.

The service assessed and managed the risk of infection, however the environment required improvement. Cleaning schedules were in place and followed. Risk assessments and audits were completed.

Staff carried out appropriate safety checks to detect and prevent the spread of infections. Regular Legionella risk assessments and monitoring of the water systems took place.

The service made sure that most 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.

People who collected medicines from a pharmacy confirmed they were involved in choosing a convenient pharmacy to suit their needs and that collection regimes were discussed with them prior to commencing treatment. The service used a review of dispensing regime form to decide on prescription regimes; this was completed by keyworkers at regular risk reviews. People confirmed they had access to naloxone and locked boxes to store medicine if required.

Staff followed good practice in medicines management including transport, storage, dispensing, administration, medicines reconciliation, recording, disposal and did it in line with national guidance.

There were systems and processes in place to safely manage medicines. Medicines were stored securely in temperature-controlled rooms which staff monitored. Staff knew what action to take when temperature readings went out of range. Staff were trained on how to use naloxone and people were encouraged to take home naloxone.

However, we found some gaps in medicines governance. There were over 40 void prescriptions that had been marked for destruction and were awaiting secure disposal by shredding.