Forward Leeds - Kirkgate

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• 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 is the first assessment for this newly registered service. This key question has been rated Good. This meant people were safe and protected from avoidable harm.

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.

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

The service had a strong proactive and positive culture of safety, based on openness and transparency. They actively listened to concerns about safety and thoroughly investigated and reported safety events.

We reviewed 5 incidents and saw that these were reported in a timely manner and categorised appropriately, with action identified where appropriate. Staff recorded incidents within 24 hours and managers graded each incident in terms of severity. Managers then determined whether they needed to complete a more detailed case review of the incident. Some incidents progressed to a case conference which took place 12 weeks after the incident.

The incident reporting and learning systems within the service were accessible and responsive. Managers ensured that all staff, including bank and agency staff were trained and supported to use them. All staff knew what incidents to report and how to report them through the dedicated online hub. There was an incident and accident policy which was in date and reviewed when required.

There had been 19 serious incidents in the previous 12 months. The most common categories of serious incidents were behaviour of concern (5), medication/ prescribing (4) and information governance (4). Managers investigated serious incidents thoroughly and identified actions and improvements to care where appropriate. Staff had access to de-brief with a psychologist and received support after a serious incident.

Staff received feedback from investigation of incidents, both internal and external to the service. Managers circulated incident data and learning by emails and during team meetings. We saw that managers had shared lessons learned from the trauma informed care practice group and case studies with staff. Managers described how safety intelligence was treated as a critical asset for the service, with data reviewed continuously to identify and mitigate emerging risks.

Learning from incidents, near misses and positive outcomes drove continuous improvement. We reviewed a serious incident investigation and learning response which outlined immediate actions taken, learning identified, governance oversight, and service-level improvements that had been implemented. The service’s response to the incident had moved quickly from incident management into prevention; there was evidence of police liaison, site controls, staff instructions, evidence preservation, personalised safety planning, and timely clinical and legal review of the incident and documentation. The service had used the incident to drive wider service learning and cultural improvement and there were clear improvements implemented to strengthen staff safety and risk management.

From our review of documents and staff interviews, it was clear that learning was not limited to one site or staff member but was translated into organisation-wide expectations.

Managers collated death in service data which included key themes and trends and identified learning. There were 96 client deaths between February 2025 and March 2026. This figure included clients in active treatment, and those who had been out of treatment for less than 3 months.

Managers held death in service meetings to review recent deaths, identify any learning, and share positive practice. They completed case reviews for all deaths and a sample of at least 20% were reviewed at an additional case conference panel review.

Staff we spoke with understood the duty of candour. We reviewed two complaints where staff had followed the duty of candour process. These both showed that staff were open and transparent and gave clients and families a full explanation on what had gone wrong.

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

There were strong, well embedded relationships with all the necessary healthcare and social care services to ensure clients had continuity of safe care, both within the service and post-discharge. Interviews with staff, care records, and documents provided by the service demonstrated a multi- agency, integrated approach to improve access to the service, reduce delays, and ensure continuity of care across pathways. 

The service demonstrated a significant area of development within its Criminal Justice pathway. This included the growth of a specialist team and the introduction of a more responsive clinical prescribing model which had improved continuity of care for individuals leaving custody. The team provided a dedicated function which focused on ensuring prison data was accurate, up to date, and transferred into the service effectively. There was also evidence of joint work with prescribers to ensure timely access to medication on release.

Managers described a proactive, risk-based approach to prison release, telling us they recognised the heightened vulnerability of people leaving prison. Their outreach provision worked at speed to ensure timely engagement with clients who had left prison. Data from 1 April 2025 - 31 March 2026 showed that 64% of prison leavers with a continued treatment need were seen by the service within 21 days, compared to the national average of 56%, according to the National Drug Treatment Monitoring Service.

The service had also expanded its hospital in-reach team. Managers described how this helped provide better support for clients during hospital admission and to ensure an effective transition into community treatment. The team worked alongside the assessment and engagement team to improve follow-up, reduce attrition, and ensure clients discharged from hospital were effectively supported and transitioned into the service.

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. There was a single point of contact team who logged and monitored all referrals. Managers had very good oversight of this, reviewing incoming referrals at the start of each week. There was also an assessment and engagement team who managed self- referred clients and completed home-based assessments for clients with barriers to assessment.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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.

Staff and leaders demonstrated effective safeguarding practice. There was evidence of strong partnership working, clear referral pathways, specialist expertise, and a proactive approach to identifying and managing risk. Staff at all levels worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Clients said that they felt supported by staff and that they helped keep them safe. They said that they felt able to share any worries or concerns with staff.

The service provided a range of initiatives aimed at improving awareness, identification, and response to safeguarding concerns. This included project work to raise staff awareness about the local safeguarding partnership board’s self-neglect policy. A safeguarding partnership board is a multi-agency group responsible for ensuring that local children, young people, and vulnerable adults are protected from abuse, neglect, and exploitation. The service worked to ensure that staff and partner agencies understood the policy, recognised the signs of self-neglect, and were aware of the appropriate processes for identifying, escalating, and managing risks.

The service had introduced designated modern slavery leads within each hub, providing staff with access to specialist advice and guidance. Managers had a good understanding of the national referral mechanism process for referring individuals who may be at risk of trafficking or modern slavery. The service had developed strong working relationships with the police and were able to identify and engage with nominated police officers responsible for modern slavery investigations.

There was a family plus team who provided support to clients with children. The team had completed work around identifying and responding to hidden harm. Hidden harm is the negative, unseen impacts that an individual’s problematic behaviour (such as alcohol or drug misuse) has on the children or dependents. Managers described how this helped ensure that risks were identified early and that families received coordinated support from partner agencies.

The service had achieved the Leeds Domestic Violence and Abuse Quality Mark, awarded by the Safer Leeds partnership on of the local authority. The quality mark recognises organisations that can demonstrate a consistent and high standard of practice in identifying, responding to and supporting people affected by domestic violence and abuse. Achievement of the award requires organisations to evidence compliance with locally agreed standards and quality criteria.

There was evidence of joint working and regular liaison with the local authority. The service had safeguarding objectives in place. One of the objectives was to further develop and build relationships with the external stakeholders. Managers could describe steps they had taken to meet this objective, including attending various multiagency meetings to provide updates and shared learning.

Staff received training specific for their role on how to recognise and report abuse. Training compliance was 100% for safeguarding awareness, 84% for level 2 safeguarding, and 79% for level 3 safeguarding. The service had increased the scope of staff who required level 3 training and were in the process of delivering this training with an expected completion date of September 2026. Staff also completed a mandatory Prevent e-learning course and an annual safeguarding refresher course.

There was a safeguarding policy in place which was subject to review as required. Staff were knowledgeable about safeguarding and knew how to raise a concern when required. They were able to identify different forms of abuse, and the signs associated with these.

Staff attended regular meetings where important information and lessons learned were shared. These included a safeguarding practice group, and a safeguarding monthly meeting. Managers categorised safeguarding concerns which fed into the services’ safeguarding strategies. They held case reviews and break out groups to discuss themes, trends and learning.

Managers reviewed periodic safeguarding reports to ensure they had good oversight of recent safeguarding concerns.

We reviewed 5 safeguarding referrals. Each referral was submitted in line with timescales in the policy and referrals were reviewed by team leaders, clinical leads, area managers and the compliance team, with a record of the referral, actions, and progress recorded.

There were safeguarding champions within the service who staff or managers could approach for advice or support.

Managers completed targeted safeguarding audits including a parental responsibility/ family plus audit. This evaluated whether parents were offered appropriate family support.

Mental Capacity Act

93% of staff had had training in the Mental Capacity Act. Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles.

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.

Staff knew where to get advice from within the provider regarding the Mental Capacity Act.

Care records showed that staff took all practical steps to enable clients to make their own decisions. For clients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions such as managing finances. The service had arrangements to monitor adherence to the Mental Capacity Act.

We scored the service as 3. The evidence showed a good standard. 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 client’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service continually worked with people to fully understand and manage risks. They did this by having a holistic approach. Care was provided which fully met client’s needs and was safe, supportive and enabled clients to do the things that mattered to them.

We reviewed 7 sets of care records during the inspection. These showed that staff involved clients in recovery planning and risk assessments. Staff completed risk assessments for each client on referral, and reviewed this regularly, including after any incident.

Clients were invited to participate in multidisciplinary team reviews and offered copies of their recovery plans. Clients confirmed they were involved in the development of these.

Staff used a nationally recognised tool to identify deteriorating clients and escalated their care appropriately. Staff took blood samples or measured client’s oxygen levels where needed, referring to external professionals or contacting emergency services when appropriate.

Staff assessed and recorded client tolerance levels to substances based on their usage or period of sobriety and their physical health, which helped them to determine the risks associated with relapse. Staff had access to Naloxone kits and distributed them to clients at risk of overdose. Clients we spoke with told us recovery plans included action to support them in case they relapsed and said staff revisited this with them regularly.

The service provided information to clients about 24-hour access to mental health liaison and specialist mental health support on admission.

Staff worked with mental health services to arrange psychosocial assessments and risk assessments for clients thought to be at risk of self-harm or suicide.

Staff shared key information to keep clients safe when handing over their care to others. We observed a morning ‘flash’ meeting and saw managers gave staff relevant updates and key information to keep clients safe. This included information about appointments, high-risk clients, safeguarding concerns, fire safety and first aid arrangements.

The service demonstrated a strong commitment to harm reduction and overdose prevention. Data showed that approximately 98% of people using the service were offered naloxone, with 97% reported to be in possession of this.

The service also achieved high levels of Hepatitis C testing, with approximately 90% of clients receiving a test.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Client areas, including the reception and meeting rooms were clean and well- maintained. The layout of each hub allowed staff to safely observe clients. There was closed circuit television (CCTV) in reception areas and airlocks.

The service was fully aware of all potential risks in the environment and managed them well. Staff completed environmental risk assessments of the environment. They checked all fire alarms on a weekly basis. There were allocated 2 fire wardens and 2 first responders at any time.

There was disabled access at each site for clients with limited mobility or physical health conditions.

We reviewed 3 clinic rooms and found these were fully equipped with accessible resuscitation equipment and emergency drugs. All equipment had been checked within the appropriate timescale.

Staff completed daily clinic room and clinical waste checks. We reviewed 5 sets of clinic room temperature records and saw these were fully completed and all temperatures within the appropriate range.

Staff carried out regular safety checks of specialist equipment. The service had enough suitable equipment to help them to safely care for clients and there were adequate supplies of vaccines, thermometers, blood pressure and ECG machines, and sufficient space to store these. Staff had easy access to alarms.

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

Leaders made sure there were always staff with the right qualifications, skills, training and experience to keep clients safe from avoidable harm and to provide the right care and treatment. They worked well together to provide safe care which met people’s individual needs.

Managers accurately 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. Data showed that average caseload numbers varied by team. The active recovery team had the highest average caseload at 40, with the specialist therapeutic outreach team having the lowest at 3. Managers described how caseloads were adjusted according to team function, intervention model, risk, complexity, outreach requirements, workforce capacity and role responsibilities.

The service had low vacancy rates. There were currently 393 posts with a total of 20 vacancies (5%).

The service had a rolling 12‑month turnover rate of 29%. Managers told us that many staff who were recorded as “leavers” often moved between partner organisations taking on new roles. They described how this supported career development, progression, and flexibility for staff while retaining skills and experience. 

The service had low sickness rates. The average absence during the last 12 months was only 4%

Staff had received and were up to date with appropriate mandatory training. The mandatory training was comprehensive and met the needs of clients and staff. Training modules included health and safety, information governance, and cyber control.

Compliance for all training modules was above 80%, except for safeguarding level 3 training, which was 79%. There was a dedicated training and development staff member who created training compliance reports. Managers reviewed these reports regularly and alerted staff when they needed to update their training.

Managers arranged for new starters to shadow in different areas of the service, which they said enabled them to gain experience across the service and develop a wider range of skills.

We scored the service as 3. The evidence showed a good standard. 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 assessed and managed the risk of infection. Staff followed good infection prevention and control procedures in line with organisational policy. This included the use of personal protective equipment. There were adequate facilities for handwashing. The service had introduced light boxes and hand hygiene kits to support both staff and clients in checking the cleanliness of their hands to improve hand hygiene standards.

The service employed an external cleaning company who visited each site 5 days per week. There was cleaning sign off sheets visible at each site confirming that cleaning had taken place. Managers also completed spot checks and walk arounds of each hub.

Each site was observed to be clean and tidy. Staff completed regular environmental and infection prevention and control audits to enable them to identify any areas of improvement and implement appropriate action plans if these were needed.

Staff demonstrated a good knowledge of infection prevention and control. Staff followed the provider’s waste disposal processes with clinical and non-clinical waste discarded and stored appropriately. Staff followed appropriate needle exchange processes and processes for identifying and treating blood borne viruses.

We reviewed 3 clinic rooms and found that staff had recorded that they cleaned equipment after each client contact. All equipment was labelled to show when it was last cleaned.

We scored the service as 3. The evidence showed a good standard. 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 systems and processes to prescribe and administer medicines safely. Prescription charts were accurate and staff kept them up to date. Staff stored and managed all medicines and prescribing documents safely. Records for the delivery and dispensing of medicine were complete and up to date. There was a process in place for medicines to be returned to the pharmacy if clients no longer required these.

Staff we spoke with knew where to access relevant medicines guidelines. There were medicines management policies in place which managers reviewed regularly.

The Kirkgate site was located next door to a pharmacy which allowed staff to liaise directly with pharmacists and escalate any prescribing or dispensing concerns. We observed staff visiting the pharmacy during the inspection

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.

Pharmacists completed medicines audits and provided reports to managers about any prescribing outliers.