Forward Leeds - Kirkgate

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. This is the first assessment for this newly registered service. This key question has been rated outstanding.This meant people’s outcomes were consistently better than expected compared to similar services. People’s feedback described it as exceptional and distinctive.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

We scored the service as 4. The evidence showed an exceptional standard. The service always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them.

The service demonstrated strong, proactive practice with a clear focus on timely assessment of needs, prevention and early intervention. There was evidence of strong partnership working including a range of preventative and outreach-based interventions in place.

Leaders used service data alongside intelligence from frontline staff to identify gaps in provision for people involved in sex work. Analysis of referral information and treatment data, combined with feedback from the street support team highlighted the need for a more support to sex workers. Leaders could evidence targeted support for sex workers through a dedicated team who worked closely with the local street outreach service. This helped ensure appropriate engagement and access to health and safeguarding support. The criminal justice team worked closely with probation services, including taking outreach activity into probation settings to build relationships and improve access to care and treatment for identified needs.

The service had invested in its own FibroScan equipment, enabling staff to complete liver scanning without the need to refer to the local acute hospital and supporting early identification of liver damage. Leaders ensured that staff at each hub received appropriate training to use this equipment.

To support the micro-elimination of Hepatitis C, on-site testing was available to clients using a SephiD machine. This machine supported fast results and enabled timely referrals to sexual health services where needed.

Staff made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them. We reviewed 7 sets of care records and saw that recovery workers completed a comprehensive initial assessment of the client in a timely manner.

Staff assessed clients’ physical health at initial assessment, and all clients were offered a health care appointment after initial assessment. There were physical health nurses and consultant medical doctors within the service who completed consultations. Staff could also arrange referrals to external services for identified physical health needs. Staff monitored ongoing physical health needs during one-to-one sessions.

The recovery plans we reviewed were personalised, holistic and recovery oriented. They identified the client’s individual needs, wishes and preferences and set out ways to manage any risks. Staff updated recovery plans regularly and offered clients copies of these.

We scored the service as 4. The evidence showed an exceptional standard. The service always planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation. They worked to develop evidence-based good practice and standards. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well

Staff provided a range of care and treatment interventions suitable for the client group. The interventions were those recommended by, and were delivered in line with, guidance from the National Institute for Health and Care Excellence and the Orange Book (UK guidelines on clinical management for substance misuse and drug dependence).

Managers described the service as ‘harm reduction and recovery focussed’. Staff completed cognitive behavioural therapy-based skills training and delivered a range of psychological-based therapies to support clients in their recovery. This included dialectal behavioural therapy and specialist psychosocial interventions. There was a consultant psychologist who staff could contact for support and advice. Staff received motivational interviewing training to support them with client interactions.

The service provided information about the many training pathways and role- specific training they offered, and we saw that there was a comprehensive and well-established approach to workforce development. Training pathways were aligned to staff roles and levels of responsibility, ensuring that learning was relevant to practice.

Managers described how the service adopted a ‘blended learning’ approach, with learning embedded through on-the-job experience, supervision, reflective practice, peer support, and formal training.

Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge through role-specific and ad hoc training. Staff had access to an extensive programme of training, and managers could describe how they had developed specialist in-house training in response to emerging need. Managers described an increasing number of referrals relating to Chemsex. Chemsex is a term used to describe intentional sexual activity while under the influence of psychoactive substances. Staff introduced dedicated training across the workforce to improve staff confidence and competence in supporting this client group.

The service had also invested in the development of psychosocial interventions. Staff completed a two-day training programme to strengthen the quality and consistency of psychosocial support offered to clients.

Other additional training included hidden harm, modern slavery, cuckooing, trauma-informed practice, motivational interviewing, domestic abuse, exploitation, family-focused practice, professional curiosity, and relapse prevention. Staff told us the training and support they received equipped them with the knowledge and skills required to work safely and effectively.

Staff ensured that clients had good access to physical healthcare, including access to GPs. There were established links with 45 GPs within the local area. Care records and staff interviews demonstrated that the service had strong links with external palliative care and respiratory care teams.

Managers provided new starters with an appropriate 2-day induction, coordinated by a dedicated trainer. The induction included talks from staff within different teams within the service, which managers said introduced new starters into how the service worked collaboratively to support the complex needs of clients.

Managers provided staff with supervision (meetings to discuss case management, to reflect on and learn from practice, and for personal support and professional development). The percentage of staff that received regular supervision was 96%.

The executive team had approved a planned and time-limited pause to its formal appraisal cycle from April 2025 to March 2026. This was due to the implementation of a new appraisal system. Throughout the pause, managers confirmed that performance management expectations remained in place. Staff and managers continued to set and review objectives, hold, and attend regular performance and development discussions, and maintain supervision and one-to-one meetings.

We found that managers took a very proactive approach in recruiting and training volunteers to work with clients in the service. There was a dedicated volunteer coordinator who supported clients in recovery to become a volunteer. Staff had ongoing discussions with clients about the volunteer programme throughout their pathway. They also reminded clients about volunteering opportunities during aftercare. There were 34 active volunteers, performing different functions include recovery support, structured work, and marketing support. Managers described how having volunteers within the criminal justice programme had enabled the service to increase the number of clients it could support.

Managers confirmed that on average volunteers collectively provided 245 hours of support to the service each week. During the previous 12 months, 9 volunteers had progressed into employment, 5 of which had secured substantive roles within the organisation.

Volunteers played a key role in the Recovery League, which brought together several local organisations to promote visible recovery, reduce isolation, and support community connections.

The service actively invested in volunteer development, with managers supporting volunteers to obtain recognised coaching qualifications.

A video showcasing the volunteer supervisor role had been used across the service and wider organisation to promote volunteering opportunities and encourage involvement.

There were clear plans to further develop the volunteer programme and increase volunteer- led community engagement. This included a new recovery cafe pilot at a local fire station.

Managers identified poor staff performance promptly and supported staff to improve either through one-to-one support or by implementing performance plans with support from the human resources team. There was a performance management policy which was up to date and subject to review as required.

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff and client interviews, care records and a review of various documents provided by the service showed that staff worked across health care disciplines and with other agencies to care for clients. There was evidence of excellent, proactive joint working with social work teams, mental health services, GP practices, sexual health services, the police, and charities. Managers attended multiagency meetings with attendance from relevant partners including police, substance misuse providers, the local council, and social care services, as part of the government’s ‘Safer Streets’ initiative.

Staff held regular and effective weekly multidisciplinary meetings to discuss clients to help improve their care. Recovery workers alerted managers to any clients they felt needed to be discussed or clients they needed support or guidance about. Multidisciplinary teams were well attended and included managers, consultants, nurses, clinical leaders, team leaders and recovery workers and volunteers.

Staff and managers confirmed these gave them the opportunity to seek advice about individual clients, engage in round the table discussions and appropriately escalate clients who needed additional support or care interventions.

Staff shared information about clients at effective handover meetings within the team. We observed a handover during the inspection and saw that staff discussed clients’ presentation, risk and concerns, identifying and agreeing any actions needed.

Staff regularly liaised with GPs, and the electronic records system showed effective two-way communication. Staff liaised with GPs regarding prescribing or medicines issues, and alerted GPs to any treatments they administered to clients.

Staff referred clients for mental health assessments when they showed signs of mental ill health, such as depression. Staff and managers knew who the designated points of contact were at the local mental health crisis teams, and inpatient mental health services.

We scored the service as 4. The evidence showed an exceptional standard. The service always supported people to manage their health and wellbeing to fully maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff recognised the importance of physical activity, social connection and community participation in promoting healthier lives and sustaining recovery. The service worked closely with local recovery organisations to provide a wide range of opportunities for people to improve their physical health and wellbeing. This included a partnership with a local recovery running group, which regularly attended service locations to encourage participation in physical activity. Staff and clients took part together in local park runs, helping to build confidence, strengthen recovery networks and challenge stigma related to substance misuse.

The service promoted healthy lifestyles and community engagement through participation in a range of high-profile events and activities. These included organised walks such as the Yorkshire Three Peaks Challenge, dragon boat races, charity fundraising events and community awareness activities, with staff and clients participating alongside one another.

The service held an annual recovery celebration event, attended by clients who had successfully completed treatment, their families, staff and community partners. Managers described how this event recognised achievements, celebrated positive outcomes and reinforced the service’s commitment to recovery-focused care. Fundraising activities undertaken throughout the year generated additional resources which were reinvested into the service.

Managers told us they recognised that clients faced barriers to accessing healthcare services, particularly in relation to oral health and respiratory care. They worked proactively with partners to improve access to this. The service had developed a partnership with a dental care charity to provide a mobile dental service for people who were unable to access NHS dental services locally. In collaboration with the charity, the service arranged six dental clinics over a four-month period, delivered by qualified dentists and dental nurses. Staff identified and prioritised those clients who needed dental treatment, and offered clients practical support to encourage attendance, in addition to providing them with transport to attend the service.

The service had also developed strong links with respiratory and palliative care services to support people living with chronic respiratory conditions. Staff attended fortnightly multidisciplinary respiratory and palliative care meetings to discuss people with complex needs and coordinate care.

Many clients were unable to access specialist respiratory services which led to the introduction of in-house spirometry clinics delivered jointly by the health and wellbeing team and a community nurse trained in spirometry. Clients could access this within service hubs, alongside joint home visits for clients unable to travel. At the time of inspection, 47 clients had been discussed through the respiratory multidisciplinary team process, and seven people had engaged with spirometry testing, enabling specialist assessment and treatment planning. This supported earlier diagnosis and management of chronic respiratory conditions.

Clients told us staff supported them in creating plans to prevent relapse, reducing their potential future need for care and support. This included providing access to a range of internal group sessions, and signposting clients to external services including alcohol and narcotics mutual aid groups.

Nurses provided advice and support around achieving a balanced diet and encouraged clients to consume healthy food and drinks. Care records showed that staff used a nationally recognised screening tool to monitor clients at risk of malnutrition. Specialist support from staff such as dietitians and speech and language therapists was available for clients who needed it, and staff arranged this through the local GP.

We scored the service as 4. The evidence showed an exceptional standard. The service monitored all people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves.

The service monitored client’s care and treatment to continuously improve it. Recovery plans contained appropriate assessments which were updated frequently to measure outcomes and progress. Managers completed audits of care records to ensure these were comprehensive and that recovery plans and risk assessments were updated and reflected individual client need.

We observed that clients discussed their expectations around outcomes for the care they received with their recovery workers. Staff discussed clinical and personal expectations during individual and group sessions. We saw staff reviewing positive progress with clients during the group sessions we observed.

Staff used recognised rating scales to assess and record severity and outcomes. This included completing alcohol audits to assess alcohol consumption and determine treatment and interventions. Staff completed treatment assessment profiles, which are a set of questions for clients at various stages in their treatment journey. They reported on this data through the National Drug Treatment Monitoring System. (NDTMS). Staff also completed PHQ-9 and GAD-7 questionnaires to screen for and measure the severity of depression and anxiety for clients.

The service monitored client readmissions. 18% of clients who were successfully treated for opiate use had re-presented at the service within 6 months. This was 11% for non-opiate use, 15% for alcohol use, and 13% for alcohol and non-opiate use.

Managers provided additional data showing the percentage of clients within the rough sleeper’s team who had stayed in treatment for at least 12 weeks or had completed treatment within that period. For the previous 12 months this figure was 100% for both alcohol and opiate use.

The service had high naloxone offer and uptake rates. 98% of eligible clients were offered naloxone, with 97% accepting naloxone. The service also had a high uptake of Hepatitis C testing with 90% of clients who were offered this accepting the test.

Managers and staff worked to make sure clients did not stay longer in the service than they needed to. Between 1 April 2025 and 31 March 2026 the service had a total of 1780 successful exits from treatment. The number of successful exits for treatment were 301 for alcohol and non-opiate use, 891 for alcohol use only, 357 for non-opiate use only, and 231 for opiate use only.

Successful exits for all four treatment pathways were higher than the national average. For alcohol and non-opiate use this was 34% against a national average of 28%. For alcohol use only this was 42% against a national average of 36%. For non-opiate use this was 34% against a national average of 31%. For opiate use only this was 9% against a national average of 6%. Managers described that one of the service’s five pillars of performance was to increase the percentage of clients who progressed to sustained recovery and told us they had invested heavily into this.

The service also consistently achieved treatment retention rates above national averages. At the time of inspection, 90% of people receiving alcohol treatment remained in treatment for 12 weeks compared with a national average of 86%; 83% of people receiving non-opiate treatment remained engaged compared with 80.5% nationally; and 79% of people receiving opiate treatment remained engaged compared with the national average of 78%.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff assessed and recorded capacity to consent clearly each time a person needed to make an important decision. Records showed that staff gave people a wide range of support to make specific decisions for themselves before deciding they did not have the capacity to do so. When staff assessed clients as not having capacity, they made decisions in their best interests and considered the individual’s wishes, feelings, culture and history.

Staff received and kept up to date with training in the Mental Capacity Act. Staff we spoke with understood how and when to assess whether a client had the capacity to make decisions about their care. They understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Health Act, Mental Capacity Act 2005 and they knew who to contact for advice. They could describe and knew how to access policy and get accurate advice on Mental Capacity Act and Deprivation of Liberty Safeguards.