Change Grow Live Barnet

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

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

At the last inspection, the provider was required to ensure staff completed mandatory training in basic life support. Training records now confirmed compliance, and all relevant staff had completed this training. Leaders had also taken steps to strengthen learning from incidents by using flash meetings and governance forums, which had been updated to include an incident section. However, during our inspection the flash meeting we observed was brief and did not record or discuss incidents, so the incident‑review function was not demonstrably embedded.

The service continued to demonstrate strengths in several areas. Staff understood safeguarding responsibilities and escalation routes, and training compliance was high. Clinical leads held Level 3 safeguarding and refresher plans were in place. Risk assessments and recovery plans were present in care records and regularly reviewed, and prescribing decisions showed multidisciplinary input. Medicines were managed safely, with standard operating procedures aligned to national guidance and consistently applied in practice. Records confirmed physical health monitoring for higher-dose methadone prescriptions, and naloxone and emergency medicines were available. The environment was clean and well maintained, with infection prevention measures in place. Incident reporting was embedded, and staff acted promptly to manage risks, including de-escalation and liaison with emergency services when required. Governance forums supported learning from incidents, and staff described structured discharge pathways and joint working with other agencies to maintain continuity of care.

However, areas for further improvement were identified. Some of the incidents we reviewed, identified actions that did not have completion dates and there had been no checks to confirm whether actions were completed or effective. Plans for unexpected exit from treatment were not documented in care records, meaning staff may not act quickly or consistently if the key worker was unavailable. Accessibility for people with mobility needs remained limited, and some staff reported uncertainty about panic-alarm use in group sessions, although leaders had reiterated procedures. Caseloads remained high, with recovery workers managing 80–100 cases, although an action plan to address this was in progress. Supervision compliance for volunteers was low, and administrative support was limited.

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.

The service promoted an open learning culture with clear routes for reporting and sharing learning through flash meetings, team meetings and governance forums. Incident and near‑miss records were structured with action owners and target dates, and changes such as updated induction content, a prescription‑change form and bi‑weekly case reviews were evident in records and staff accounts.

Leaders told us the service recorded around 50 incidents in the last 12 months, most commonly violence and aggression, medicines‑related issues (such as prescriptions not located or hospital admissions not communicated), and occasional data breaches. They also reported 3–4 deaths per quarter, reviewed through governance processes.

All staff received incident‑reporting training, with refreshers delivered by the governance lead, supporting visibility of risks and timely learning. Staff managed incidents promptly and maintained engagement. For example, de‑escalating when a person attended under the influence and arranging safe exit with follow‑up, or clarifying plans after a prescription dispute, with an apology recorded. As a result of learning from violence and aggression incidents, sessions in flash meetings aimed to remind and reinforce the procedure staff should follow when faced with this situation.

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.

We reviewed 10 care records. Risk assessments and recovery plans were present, clearly documented and regularly reviewed, and prescribing decisions showed multidisciplinary input. Staff described structured discharge pathways and joint working with hospitals, maternity services, probation and other providers to support continuity.

Staff consistently described what they would do in practice should a person exit unexpectedly from the service. This included contact with next‑of‑kin, attempting rapid re‑engagement and discussion of risk with them. Although formal plans for unexpected exit were not consistently documented in care records, we saw evidence in some records that staff acted promptly and followed their described approach, including contacting next‑of‑kin and attempting rapid re‑engagement. Routine triage occurred within 7 days of referral. Leaders described an urgent pathway for high‑risk referrals.

Since being awarded a new five‑year contract in April, the provider had introduced two new entry into service recovery worker roles to improve access and reduce waiting times. Leaders had highlighted timely access to the service as a potential risk and reviewed it regularly through their service level risk register. Additional actions implemented and regularly reviewed included an updated process guide for reviewing referrals, regular review of performance data and dedicated triage appointments. The service was also reviewing its out of hours provision, to increase the number of appointments available.

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 understood safeguarding responsibilities and escalation routes, with access to a safeguarding lead and weekly surgeries. Training compliance was high and clinical leads held Level 3 safeguarding; leaders planned refreshers for roles with older training dates. We saw four safeguarding referrals in the last 12 months with follow‑up evidenced in care and treatment records. An internal review prior to inspection identified examples of risks categorised without sufficient context (for example, “risk of harm to others” without a narrative); refresher guidance on categorisation was shared and discussed in team meetings.

The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Records confirmed risk assessments were completed and updated, and incident entries showed appropriate immediate actions (including de‑escalation and, where required, liaison with emergency services). People told us they understood group rules and reflected on the impact when someone attended under the influence; care and treatment records showed staff sought to keep people engaged and clarify expectations after incidents.

Risk plans were updated after changes, and people using the service and their carers confirmed they were involved with and knew about these changes.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Whilst the environment supported safe care in most areas, staff told us accessibility for people with mobility needs was limited, entrance visibility was restricted, and some rooms became uncomfortably warm in hot weather. Incident records showed one end‑of‑day security lapse. A small number of staff reported uncertainty about panic‑alarm use in group sessions. Leaders had reiterated the procedure to standardise responses across teams.

People described premises as clean, quiet and private. Staff confirmed naloxone, adrenaline and a defibrillator were available. Environmental risk assessments and daily/weekly/monthly checks were in place; fire safety measures were maintained; and a mock panic‑alarm test confirmed an audible alarm with first‑responder attendance.

The provider was making improvements to ensure 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.

Vacancies and sickness led to raised caseloads, with recovery workers managing 80–100 cases and some team leaders holding significantly more. Staff raised concerns about workload distribution, limited administrative support and frustration with duty cover arrangements.

Team Leaders now deliver monthly case management and audit sessions, supported by individualised plans for staff with the highest workload pressures. Weekly case management reviews and audits by senior managers aim to strengthen oversight and support staff in managing caseloads effectively.

Governance minutes also showed a significant decline in timely triage completion from 52% in April to 11% in July, although actions had been introduced to address this. Monitoring of outcomes was in place, but compliance with key indicators such as risk reviews and Treatment Outcomes Profile returns was below target, and improvement actions were recently introduced so impact could not yet be demonstrated.

Safer recruitment checks, structured induction and core training were in place; professional registration was verified. All relevant staff had completed mandatory training in Basic Life Support (BLS), confirmed through training records. People generally experienced continuity of care, with appointments kept or promptly rescheduled.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Areas were clean and well-maintained, with in-date consumables. Infection Prevention and Control (IPC) arrangements reflected the service’s risk profile, with appropriate ventilation, sanitising materials, bio-spill kits, and sharps bins in place. However, a health and safety audit identified several issues: an overdue IPC risk assessment review, incomplete electronic records of routine water-temperature checks, and the need to improve cleaning contractor compliance. In response, records showed that the provider updated the IPC risk assessment, implemented recorded water-temperature checks with remedial actions, and escalated contractor-related issues. A subsequent update from the provider after the inspection advised completion of these actions.

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.

Medicines were managed safely and in a way that supported person-centred care. People told us they received clear information and were involved in decisions about their medicines. Staff described how they used national and regional forums to discuss complex cases and share good practice, and how supervision supported safe prescribing decisions.

Standard operating procedures (SOPs) were in place for each prescribing pathway, including opioid substitution therapy, detoxification, and relapse prevention. These SOPs aligned with national guidance such as NICE recommendations. Staff demonstrated awareness of these procedures and described how they applied them in practice.

We reviewed five care records across different pathways. Each showed consistent documentation of prescribing decisions, physical health monitoring, and risk assessments. For example, records included Electrocardiogram (ECG) monitoring for higher-dose methadone prescriptions. Staff interviews and a review of care and treatment records confirmed that SOPs were being followed in practice, with evidence of clinical oversight and adherence to safe prescribing protocols.

Medicines were stored securely and appropriately. Staff checked existing prescriptions during assessments using GP records and confirmed details directly with the person and their pharmacy. They described working collaboratively to reduce risks, including monitoring for signs of misuse or diversion and adjusting treatment accordingly. Naloxone was available in both nasal and injectable forms, and staff were familiar with its use.