Scovell Street, Salford

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection we rated well-led as Good. At this inspection the rating has remained Good. 

Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected analysed data about outcomes and performance. They used this to identify improvements. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We have not awarded this service a score for Well-led.

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

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff knew and understood the provider’s vision and values and were committed to applying them in the work of their team. 

The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. We saw posters within the service which displayed the values which were “be still, listen, learn, know.” 

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Staff meetings were held weekly and staff used this forum to discuss any services changes or new ideas.

Staff could explain how they were working to deliver high quality care within the budgets available. 

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. The manager was a qualified nurse who had maintained registration and knew the service well.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. The service focused on fostering a drug and alcohol recovery culture and had established a framework to assess emotional and social learning skills, aligning these evaluations with workforce development to support and promote recovery. It also provided ongoing development through its dynamic Intelligence Learning Programme, ensuring staff continually enhanced their skills and knowledge, delivering customised training, coaching and leadership development that embedded recovery focused competencies across the workforce, enhancing capability and readiness for key roles. 

Leaders were visible in the service and approachable for clients and staff. Staff and clients spoke highly of senior leaders and confirmed that they could readily approach them about any issues or concerns. The Chief Executive Officer (CEO) had hosted two corporate training days, providing staff with opportunities to share ideas for improving the service, including insights on working with neurodiverse clients. Additionally, the CEO frequently visited the service to meet informally with clients, fostering open communication and strengthening relationships across the community. 

Leadership development opportunities were available, including opportunities for staff. For staff not currently in management or leadership roles, the service offered a range of development and training opportunities designed to build leadership skills and confidence. Drawing on its expertise in working with individuals with lived experience, the organisation provided ongoing training and mentoring that enabled staff to become role models within their teams. A structured leadership training model was being developed to further support this pathway. The organisation had a strong track record of helping keyworkers progress into team leader and supervisory positions, reflecting its commitment to nurturing talent and fostering internal career growth.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Clients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. The provider had an independent manager designated as a Freedom to Speak Up (FTSU) Champion, who was not aligned to a specific location but remained impartial and separate from day-to-day management. This manager was readily accessible to staff, providing a confidential and supportive channel to raise concerns, share ideas, or seek guidance. By having a dedicated, independent point of contact, staff could feel safe and empowered to speak up, ensuring that issues were addressed promptly. 

Managers and staff had access to the feedback from clients, carers and staff and used it to make improvements. 

While clients, families, and carers were not directly involved in formal decision-making processes such as recruitment panels or strategic planning, their input was considered through client feedback and staff discussions at corporate seminars. This indirect involvement allowed their experiences and perspectives to inform improvements and influence changes to the service, helping shape new ways of working and enhancing overall service quality. 

Clients and staff routinely met with members of the provider’s senior leadership team and governors to give feedback. 

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

There was an equality and diversity champion within the service who was a former resident and now volunteered within the service, providing guidance and support to current clients with their step work, demonstrating the positive impact of lived experience in fostering recovery.

Staff were able to apply to work flexibly and some had flexible working agreements to account for personal circumstances such as caring responsibilities and health issues. 

Managers put reasonable adjustments in place for staff members to help them carry out their role. 

The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the client group. 

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

There was a clear framework of what must be discussed at team or management level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. 

Staff had implemented recommendations from reviews of incidents, complaints and safeguarding alerts at the service level such as alert flags added to the database system detailing relevant risk and communication needs, additional training delivered to strengthen staff understanding of trauma responses and to promote more sensitive, preventative approaches to emotional dysregulation and reinforcement of  harm reduction messaging to both clients and staff following evidence of substances being brought into the service.

Staff undertook or participated in local clinical audits. There were monthly audits to review medication records to ensure accuracy, safe storage, and compliance with administration protocols. Findings were used to address any discrepancies, reinforce staff training, and maintain safe medication practices. The audits were sufficient to provide assurance and staff acted on the results when needed. Staff routinely audited client care records and to ensure completeness, accuracy, and compliance with regulatory and organisational standards. Findings were used to update staff guidance, improve record-keeping practices, and enhance person-centred care. 

Staff understood the arrangements for working with other teams, both within the service and externally, to meet the needs of the clients. This included liaison with the police, the probation service, prisons and housing and benefit providers.

All service-level and organisational-level risks were reviewed regularly, scored for likelihood and impact, assigned clear ownership, and updated to reflect emerging issues, including changes in clients’ needs, local public health guidance, or sector developments.

Staff maintained and had access to the risk register to ensure the service ran safely, effectively, and sustainably. Risks identified included regulatory and compliance risks, including adherence to CQC standards, safeguarding legislation, and data protection requirements, and these were managed through clear policies, audits, and staff guidance. Human resources risks are also recorded, including staff turnover, absence, burnout, or skills gaps, and were addressed through recruitment planning, supervision, ongoing professional development, and wellbeing support. Staff could escalate concerns when required and  staff concerns matched those on the risk register. 

The service had plans for emergencies for example, adverse weather or a flu outbreak. 

Where cost improvements were taking place, they did not compromise client care. 

The service used systems to collect data that were not over-burdensome for frontline staff.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care. 

Information governance systems included confidentiality of client records on the electronic recording system.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and client care. 

Information was in an accessible format, and was timely, accurate and identified areas for improvement. 

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Managers and staff actively engaged with a range of external stakeholders to ensure the service met local needs and maintained high-quality standards. For example, the provider’s bimonthly Achieve Partnership meetings with the main NHS subcontractor, included services such as mental health, children’s services, housing and criminal justice. Quarterly meetings with the local main NHS subcontractor, who reported to commissioners, reviewed service performance, discussed outcomes, and planned improvements in line with community needs. The service collaborated with the police and local authorities to support safeguarding initiatives, including joint case reviews where residents were at risk of harm, and coordinated responses to incidents in the community. such as commissioners and Healthwatch.

Clients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback. The Chief Executive (CEO) had hosted two corporate training days, providing staff with opportunities to share ideas for improving the service, including insights on working with neurodiverse clients. Additionally, the CEO frequently visited the service to meet informally with clients, fostering open communication and strengthening relationships. 

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Staff had opportunities to participate in research. 

The service used a stage-based approach to post-treatment development, ensuring continuity of care and reinforcing the skills acquired during the residential programme. Clients could access regular follow-up sessions, personalised growth plans, and mental fitness coaching. Peer support groups were facilitated to maintain social connection, accountability, and a sense of community, reducing the risk of relapse and promoting long-term wellbeing. 

Former service users were offered opportunities to continue their development within the programme by taking on roles as lived-experience peers, receiving training as coaches, and moving into full-time employment. 

Through the combination of Dynamic Intelligence Learning, personalised post-treatment development, and structured peer pathways, THOMAS ensured that clients left the programme with practical tools, emotional resilience, and social competencies aimed to support their continued recovery, personal development, and successful reintegration into society.

In addition, the service had taken part in an ongoing PhD study, led by the CEO, exploring the development of lived-experience workers within the service. This research examined how former residents could be trained and supported to work as peers and coaches, contributing to the programme while developing professional skills and career pathways. Insights from this study were informing staff development, peer mentoring structures, and post-treatment support with the aim of further enhancing the quality of care and the recovery experience for current clients.