Turning Point Leicester City Substance Misuse

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 was the first assessment for this service. This key question has been rated Good.

This meant people were safe and protected from avoidable harm.

Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients 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.

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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There was 1 serious incident in the service within the last 12 months. This was thoroughly investigated using robust processes.

Staff used an electronic incident reporting system. All staff knew how to report an incident and what types of incidents they were required to report. These were shared in daily meetings with all staff and via email. Staff told us they were given debriefs, which facilitated learning. The service conducted monthly mortality and morbidity meetings and completed initial review reports within 72 hours of a client’s death. Where further investigation was required, more detailed reports were completed within 60 days; 3 such reports had been completed within the last year. A recommendation from one of these reports included improving liaison with the local mental health trust to strengthen hospital discharge processes and communication between services. The reports also highlighted good practice and shared lessons learned.

Learning was shared with staff through a quarterly county-wide bulletin, as well as daily handover meetings and individual team meetings.

The service implemented harm reduction champions in all teams to ensure all teams had access to the same, up to date information to improve client care

The service had a detailed and up to date duty of candour guide, which emphasised the importance of learning.

The provider acknowledged that 72-hour reports had identified lessons about communication between services, including GP surgeries, hospitals, and Adult Social Care. The incidents reviewed were not found to have directly contributed to any deaths in the last 6 months, and the provider had taken steps to act on these lessons to improve future client care.

All staff spoken to also felt able to raise safety concerns to their team leaders.

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 had an engagement team made up of experienced recovery workers who managed the general running of the reception and assessments schedule. They liaised with the national customer service teams to screen self-referrals and booked slots when required. The service also accepted referrals from professionals.

Target timescales were 21 days for non-urgent referrals and 7 days for urgent referrals, from referral to the start of treatment. The data provided showed clients were seen within this timescale, and waiting times were below the national average.

Clients released from prison or discharged from hospital with prescribing needs were seen on the day of their discharge, to promote continuity of care. Same-day prescribing was also offered to other high-risk clients, including those at risk of disengagement, pregnant clients, homeless clients, and those with complex health concerns. Providing prescriptions on the same day promoted safe and timely access to treatment.

Clients told us they were given sufficient information and felt involved during the assessment process.

The evidence showed an exceptional standard. The service worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. They had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They always shared concerns quickly and appropriately.

The service had processes in place to identify and respond to safeguarding concerns and staff were able to identify different types of abuse. There were relevant safeguarding policies and procedures in place. At the time of inspection, 94% of staff had completed Level 1 safeguarding training and Level 2 safeguarding training had been completed. There were designated adult and children safeguarding leads with separate pathways to manage safeguarding concerns.

Safeguarding leads delivered safeguarding training and provided 1:1 supervision for complex safeguarding cases. Safeguarding leads completed audits, shared findings with the wider team and implemented training based on findings. The October 2025 audit noted positives including completion of family assessments and opening safeguarding cases on client notes. Improvements identified from the audit included consistency of practice with pregnant clients and improving risk assessment quality. Supportive training sessions were delivered in response to these as well as identifying experienced staff to escalate concerns to. There was a team for families with complex needs that was managed by safeguarding leads. This team completed enhanced family visits and groups and provided parenting groups and a coping skills group for young people.

Safeguarding leads had good working relationships with external agencies and had regular meetings with adult social care, the mental health central access point and the local community mental health team. Child safeguarding leads attended child protection conferences where required.

The service had a domestic abuse lead who attended multi-agency risk assessment conferences (MARAC), which were chaired by the local authority. The service also had a pregnancy lead, who embedded a fortnightly MDT meeting where each case is regularly reviewed. Pregnant clients were automatically referred to specialist midwives, and the service had established effective working relationships with them.

Staff reported that safeguarding issues were regularly discussed in multi-disciplinary meetings. Managers had oversight of safeguarding alerts.

There was a young person’s team who supported those under 18 with substance use issues. The service also worked with ‘New Futures Project’ in the local area, a women’s therapeutic recovery service who work with people who have experienced domestic abuse.

The service reviewed the reports that had been completed within 72 hours of each client’s death and had identified missed opportunities for liaison with other agencies, including social services. This learning was used to improve future practice.

All 9 clients reported feeling safe and respected by staff.

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 12 client care records and found that risk assessments were regularly reviewed and clearly demonstrated clients’ risks.

Five clients told us they felt involved in their care. The other 4 were unable to comment as they were new to the service.

There was evidence of consent and sharing of information being discussed with clients throughout all the care records reviewed. All client records that were reviewed had evidence of harm minimisation being discussed.

Staff were encouraged to offer naloxone, a drug that reverses opiate overdoses, to all clients to reduce the risk of overdose.

Clients were risk assessed for their suitability of keeping medication at home – this involved staff visiting clients’ homes to assess suitability and for ongoing monitoring of medication. Clients entered a joint safe storage agreement and received a locked box to keep their medication in, particularly if children lived in the home. Clients were given more opiate substitute therapy at one time if risk assessed so that they attended the pharmacy on a less frequent basis and their lives were less disrupted.

Staff would often aid client engagement by changing meeting points and attending various hot spots around the city if required.

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 performed risk assessments of the environment, including fire safety. Staff members were allocated fire safety roles for the day during the morning meeting.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. All rooms were equipped with lanyard panic alarms for safety in the event of an emergency. The service was clean and tidy. The service had arrangements in place for the collection and disposal of clinical waste.

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.

The service did not use any bank or agency staff. There was an established staff number of 150.4 full-time equivalent (FTE) staff, with 146.4 (FTE) staff in post with only 4 FTE vacancies unfilled.

Leaders told us these gaps were in the alcohol team, as staff were leaving for promotions/further opportunities. There was also a change in funding, limiting the number of vacancies that could be advertised. However, the provider has been able to advertise for 2 roles. This was a recognised risk to the service on the provider risk register. The operations manager managed this risk and implemented changes such as temporary support from other teams with assessments and case management, pending new staff starting to ensure that client care was not impacted. We reviewed average caseloads for all the teams, and they were within both national and provider target. We spoke to 19 staff members in a variety of roles, none of the staff we spoke to felt caseload numbers were an issue. Staff also told us they did not feel concerned about staffing levels and there was always someone with experience and managers available if needed. Sickness was not a significant concern in the service. Figures were 2.7% for September, 6.6% for October and 6.3% for November.

Staff received appropriate training for their roles, and overall compliance with mandatory training was 91% at the time of our assessment.

Most staff and clients we spoke to reported that generally appointments were not cancelled. However, 1 client reported their appointments were sometimes cancelled.

There was an induction passport to help new staff, which includes mandatory e-learning and shadowing. The staff we spoke to reported receiving regular supervisions and appraisals.

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.

The service had an infection prevention and control (IPC) policy in place which had been recently reviewed. The service also had an IPC audit tool which was last completed in April 2025. Overall, this had mixed compliance. There was evidence of compliance for infection control management, waste disposal, safe handling of specimens, and handling of sharps. However, there was poor compliance for environment, hand hygiene prompts and immunisation of colleagues. The audit identified areas to follow up to ensure adherence to infection control policies. This included mending furniture, displaying posters, replacing broken bins, and completing risk assessments and exemption statuses for staff. None of these things appeared to be a concern during the inspection, showing effectiveness of the audit.

The service subcontracted a cleaning company, and the environment was observed to be clean and tidy during our assessment. Clients also told us they felt the environment was well-maintained.

There were display boards with client information regarding Blood Borne Viruses and sexual health screening.

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 followed good practice in medicines management (that is transport, storage, dispending, administration, medicines reconciliation, recording and disposal).

The controlled drugs book was well maintained, up to date, and accurately recorded all relevant details.

The medicines policy provided clear guidance on managing risks to clients regarding drugs and alcohol, ensuring staff followed defined procedures to minimise harm and maintain safety.

Emergency drugs, including naloxone and adrenaline, were present, in date, and accompanied by relevant policies for their management and use, ensuring staff could respond effectively to clinical emergencies.

Clients told us they received advice regarding their medication and were involved in decisions about their medication and that their treatment was reviewed every 3 months.

We found nurse prescribers and doctors were appropriately trained. Prescribers met fortnightly to discuss incidents relating to medication and any concerns regarding client’s treatment.

Staff reviewed the effects of medication on clients’ physical health regularly and in line with National Institute for Health Care and Excellence (NICE) guidance.

Prescribers told us they felt the assessment process was comprehensive. Prescribers attended the local community and served breakfast at weekends to identify vulnerable clients and start medication sooner.