Turning Point - Suffolk SU Drug and Alcohol Service

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.

At our last assessment we rated this key question as requires improvement. The service was in breach of regulation 12 (safe care and treatment). The service had made improvements and is no longer in breach of regulations. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

Staff reported serious incidents clearly and in line with policy. Staff knew what incidents to report and how to report them. Staff recorded incidents on an electronic incident reporting system. All incidents were reviewed by the quality manager. Staff understood the duty of candour. They were open and transparent and gave people a full explanation if and when things went wrong. Leaders investigated incidents where appropriate.

The service had up to date incident reporting processes for internal incidents. We reviewed evidence that demonstrated the service understood its responsibility to submit statutory notifications. Governance processes showed leaders had oversight of incidents and took action to manage risks.

Leaders investigated incidents thoroughly. The hub managers met regularly. They reviewed incidents and identified any themes or trends. Information from these discussions was reported up to clinical governance meetings.

Staff met to discuss learning from incidents which was shared in a variety of ways. Managers discussed learning with staff in team meetings and staff provided examples of new training being delivered about what to do if unknown substances were found on site. This training was delivered as a result of learning from an incident.

The service worked with people and partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. The service ensured continuity of care, including when people moved between different services.

The service screened referrals to check whether people met their eligibility criteria. If they did not meet the criteria, people were signposted to more appropriate services. If people were assessed as suitable for the service they were offered a full assessment. At the start of treatment people were assigned a keyworker. People assessed as high risk could access priority appointments.

The service had clear treatment pathways. There was a clinical team and a criminal justice team with separate pathways depending on the person’s needs. People were allocated workers for an initial timeframe, depending on their needs and pathway. However, staff worked with people to continue to assess their needs and adjust the timeframe as required.

The service had a policy for people who disengaged from the service. People were given information on harm reduction, overdose risk and advised where they could access support from community agencies. The GP and other relevant agencies were informed.

The service had a protocol in place for service users who did not attend appointments to try to re-engage them with the service. The protocol included attempting to contact the person or their family or friends. Staff also contacted outside agencies such as the service user’s GP or local pharmacy to see if they had been in contact with them. If staff were able to contact them, they arranged to re-engage them with the service or discharge them. If they did not want to be discharged, they could return to the service when they were ready.

Staff built discharge planning into people’s treatment plans. There were pathways for moving away from structured treatment to receiving additional support. Staff worked collaboratively with partner agencies in the community to ensure people had a support network once they were ready for discharge. Employment specialists from a partner agency were based at all 3 hubs. They supported people to search for jobs and prepare for interviews.

The service worked with people to understand what being safe meant to them as well as with partners on the best way to achieve this. The service concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and the service make sure they shared concerns quickly and appropriately.

Staff received training on how to recognise and report abuse, appropriate for their role. Staff compliance with level 1 safeguarding training was 92%. All staff members who had contact with people who used the service also completed level 2 safeguarding training. The compliance rate was 75% at the time of the inspection, and we saw evidence that the compliance rate increased to 85% in subsequent months. Managers completed a safeguarding for managers workshop, which enabled them to provide additional support to staff if required. The provider had a safeguarding lead and the service had a local safeguarding lead.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff gave us examples where they had raised safeguarding concerns relating to financial abuse and domestic violence.

Staff knew how to recognise adults and children at risk of or suffering harm and worked with other agencies to protect them. The service had developed good working relationships with multiple external agencies, and staff attended professionals meetings with other agencies as required.

The service held a daily safeguarding meeting which was open for all staff to discuss any safeguarding cases they had. Staff were given advice about actions to take, and leaders provided support to manage complex safeguarding cases.

The service had robust systems for tracking the progress of safeguarding referrals. Safeguarding referrals were logged and discussed at safeguarding meetings. New referrals were assigned to the hub manager as the incident owner. There were systems in place to quickly obtain certain information from the local authority. Leaders from the service attended various meetings including criminal and exploitation panels.

There were clear procedures in place to promote people’s safety. The safeguarding adults and children's policies signposted staff to the local safeguarding adults or children procedure for guidance to ensure staff were aware of how to raise a safeguarding concern. Safeguarding noticeboards in the service’s hubs also provided contact details for the local safeguarding authority, as well as who the hub safeguarding lead was.

The service worked with people to understand and manage risks by thinking holistically so that care met their needs in a way that was safe and supportive and enabled them to do the things that mattered to them.

Staff completed risk assessments for each patient using a recognised tool. Staff assessed risks at the point of screening referrals and assessing people for suitability for the service. Staff completed a full risk assessment at the start of treatment. We reviewed 13 risk assessments. All risk assessments we reviewed included a full assessment of drug use and injection history where applicable, assessment of previous access to treatment, evidence of blood borne virus (BBV) assessments, harm reduction advice provided and assessment of motivation to change.

The service was proactive in educating people about harm reduction and there was a harm reduction lead at each hub. Each hub lead was supported by an overall harm reduction lead for the service. Staff worked with service users to provide advice and tools to reduce harm. They also worked with local external agencies to support this work. Staff were able to provide people with kits to test substances for harmful content. They provided people with safe equipment. Staff provided people and local agencies with naloxone. Naloxone is a medicine that is used to reverse or reduce the effects of opioid use. Staff encouraged people to carry naloxone, as well as their families so they could support them if needed. The service recently launched a naloxone click and deliver service. This was available through the service’s website.

Staff worked with people to develop and use crisis plans according to their needs. All records showed plans for unexpected treatment exit and records showed involvement with other agencies where needed. Unexpected treatment exit plans included information to assist staff to support people to re-engage with the service. If people did not attend an appointment, staff contacted them to help them re-engage with the service.

Staff demonstrated an understanding of the management of risk and were aware of the procedures to follow in the event of an emergency or if they needed further support. Staff followed clear personal safety protocols, including for lone working. For example, the criminal justice workers carried out joint visits with another worker or alongside the police.

However, risk assessments were not always updated within appropriate timeframes. In the records we reviewed, 5 out of 13 risk assessments were not up to date or had been updated outside of the 12-week timeframe.

The service detected and controlled potential risks in the care environment and made sure that the equipment, facilities and technology supported the delivery of safe care.

Staff completed and regularly updated thorough risk assessments of all areas and removed or reduced any risks they identified. Staff conducted regular health and safety audits. Fire risk assessments were updated on an annual basis, with other fire safety checks completed on a weekly basis. Fire drill rehearsals took place every 3 months.

All interview rooms at the Ipswich and Lowestoft hubs had alarms, and staff were available to respond. Staff at the Bury St Edmunds hub wore personal alarms which were signed in and out. Alarms were tested monthly as part of the monthly environmental checks. All clinic rooms had the necessary equipment for people to have thorough physical examinations.

The service had a safety management system where health and safety checks were colour coded to indicate whether they had been completed. There were health and safety representatives at each hub. There was oversight of health and safety audits at clinical governance meetings.

The hub at Bury St Edmunds had recently moved to a new location. It was a welcoming and open environment with access to activities such as puzzles and table football. All locations were clean and well maintained. All sites were able to support people with mobility needs. The sites were all based across multiple floors, but there was a lift at the Bury St Edmunds site and staff could see people in a ground floor room at Ipswich and Lowestoft.

The service did not always have always enough qualified, skilled and experienced people to provide safe care that met people’s individual needs.

The service did not always have enough staff to keep people safe. Data provided by the service identified a total of 15.1 vacancies across the service. There were 5 recovery worker vacancies at Bury St Edmunds, 5.5 recovery worker vacancies at Ipswich, 1 recovery worker vacancy at Lowestoft and 2 recovery worker vacancies in the criminal justice team. There was 1 team leader vacancy at Lowestoft and 0.64 full time equivalent (FTE) vacancy in the administration team. The service did not use agency staff. There were occasions when staff were paid extra hours to support the service and 3 staff were employed on a zero hours contract during the period between May 2024 to May 2025.

The impact of the recovery worker vacancies meant that caseloads were higher than expected, which also impacted the amount of groups staff were able to provide, referral to assessment times, timely completion of risk assessments and key worker consistency.

Turnover of staff was 13.9% from November 2024 to April 2025, with 12 staff who joined the service and 14 staff who left the service. Increased staff turnover impacted on consistency of keyworkers for people who used the service.

Leaders put mitigations in place to reduce the impact of vacancies where possible, and to improve recruitment. Leaders arranged staff between the hubs to support those that had fewer staff. At the time of our inspection, the service was planning 3 recruitment events based at the corresponding hub locations. Leaders were focussing more on recruiting and retaining the right people. They had a values exercise to ensure potential candidates had an improved understanding of what the job involved.

People who used the service reported that their groups or appointments mostly all took place as planned and were rarely cancelled. However, some people stated that appointments were not always regular and felt this could be due to staff shortages and changes in keyworkers.

Staff received and were up to date with appropriate mandatory training. The overall compliance rate for all mandatory training completion was 82%. The training was appropriate for the service user group using the service. The lowest compliance was in two new courses that had been introduced the month before the inspection took place. These were courses on case notes (41%) and person-centred approach (40%). Leaders had plans in place to ensure all staff became compliant with the new training courses. The service provided additional training workshops to support the development of staff.

Staff received regular and thorough supervision. Supervision was due to be provided on a quarterly basis but was often completed more frequently. Leaders reviewed a sample of worker’s cases with them to go through service user’s pathways and recovery plans. They set actions which were reviewed and signed off at the next supervision.

Staff were given a comprehensive induction to the service to ensure they were prepared for the role. Staff completed an induction checklist to ensure they were competent to carry out their duties and identify other areas for their professional development.

Leaders supported staff to develop through yearly, constructive appraisals of their work. 76% of staff were up to date with their appraisal at the time of the inspection and all remaining staff had their appraisal booked in for the following month.

The service assessed and managed the risk of infection, detected and controlled the risk of it spreading and shared any concerns with appropriate agencies promptly.

During an inspection in October 2018, the provider had the following breach: The provider must ensure the area for community-based drug testing is fit for purpose with hand washing facilities. Improvements to the community drug testing environment were required at the Ipswich hub and improvements in access to handwashing facilities were required at the Ipswich and Bury St Edmunds hubs. During this inspection, the service was no longer in breach of regulations. The location of the community-based drug testing was moved to an alternative space in the building with access to handwashing facilities. The Bury St Edmunds hub had moved to a new location since the last inspection and appropriate handwashing facilities were available.

Staff made sure cleaning records were up-to-date, and the premises were clean. Staff followed infection control policy, including handwashing. The service conducted handwashing audits across all sites with a high level of compliance in all areas. Staff compliance rate for infection prevention and awareness training was 87%.

The service made sure that medicines and treatments were safe and met people's needs, capacities and preferences by enabling them to be involved in planning, including when changes happened.

There were system processes in place to safely manage medicines. Medicines were stored securely in temperature controlled areas which were monitored. Staff knew how to escalate concerns when a temperature reading went out of range. Staff could access emergency medicines easily. Staff were trained on how to use naloxone and people who used the service were encouraged to have a supply if needed.

Controlled drugs (CD), medicines with additional storage and recording requirements, were stored and recorded appropriately. However, when stock for an individual service user was received, this was not always recorded clearly in the CD book. Records did not clearly show the amount of medication which had been received into stock which meant the record was not accurate.

Medicines and controlled stationary were stored securely. There were paper and electronic records used to show administration and prescriptions issued.

The service had a clinical administrator based at each hub whose role it was to oversee the correct issuing and completion of prescriptions including those people on a repeating cycle. Once a prescription was generated this was signed by an independent prescriber or doctor. Prescriptions could be given directly to the person or posted to their supplying pharmacy. Each prescription issued was logged when sent and a copy put into the person's records.

People were asked for their consent before their own GPs were contacted. Medical and drug histories were checked prior to prescriptions or medicines being issued. People were invited for regular medicines reviews and complex cases were discussed at the multi-disciplinary team meetings. People were offered a urine drug screen initially and during their time with the service. People were offered blood borne virus tests prior to treatment (hepatitis B, hepatitis C, and HIV). If a service user tested positive for hepatitis B, nurses were able to administer the hepatitis B vaccine. People were offered regular physical health checks when they visited the clinic.

Medicines incidents were reported on an electronic system and investigated by the senior leadership team. They were also discussed at governance meetings and learning was shared with staff. Non-medical prescribers (NMPs) were supported by clinical leads and pharmacists. Pharmacy staff provided education and training and facilitated peer support groups.

The service worked closely with local GP's to support deprescribing and review of medicines that can be addictive, such as those prescribed for pain and to help with sleep. The service also worked with universities and mental health trusts as part of a research project into addiction.

The provider had a system for managing patient safety alerts and ensuring that information was disseminated. There was a dedicated pharmacy service. Staff provided clinical support as well as attending meetings to discuss errors and improvements. Audits were completed regularly, and action plans were created and implemented from these. Pharmacy staff reviewed the action plans to ensure they were completed.