Turning Point - Suffolk SU Drug and Alcohol Service

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 assessment we rated this key question as good. At this assessment the rating has remained good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 86 (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 shared vision, strategy and culture that was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and their communities.

Staff and leaders knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff had the opportunity to contribute to discussions about the strategy for their service. The service ran 3 away days throughout Spring 2025 where staff took part in a strategy workshop.

The service provided opportunities for people who completed treatment to train and work as peer mentors. The course was externally accredited and provided peer mentors with a qualification. The peer mentors we spoke with were extremely positive about the service. They spoke about how important it was to be able to use their lived experience to support other people. Peer mentors were involved in strategy discussions relating to the service and attended the away days. Some peer mentors were invited to share their stories, which staff told us had a profound impact on them. We observed staff working collaboratively and equally with peer mentors. Peer mentors were fully embedded into the structure of the service.

The provider ran a national criminal justice forum to support the criminal justice teams across the whole organisation. Staff from the service’s criminal justice team participated in the forum meetings, where staff shared learning and best practice. Discussions took place at a systemwide level and included working with partners and improving information shared with people who use the service.

The majority of staff we spoke to told us they felt there was a positive culture within the service and among their colleagues. However, some staff we spoke with told us there had been some tension and differences in communication which could impact morale.

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. They had the skills, knowledge, experience and credibility to lead effectively and did so with integrity, openness and honesty.

Leaders and staff were compassionate and inclusive. Many initiatives developed by the service were created in coproduction with people who use the service and peer mentors with a view to them becoming sustained by them. For example, the aftercare groups at Lowestoft were run by people who previously completed treatment. This in turn meant that people who had been discharged from the service were still able to attend and benefit from the aftercare groups. The peer mentors we spoke to told us that they felt they were respected and treated the same way as any other staff member in the organisation. The service had a strong focus on coproduction and empowered service users by recognising the value they added to the service. Leaders and staff recognised that the service user group they worked with was often not typically supported within society. Staff and leaders challenged this perception and supported people with compassion.

Leaders had the skills, knowledge and experience to perform their roles. The registered manager had held the post since December 2016, which provided continuity for the service. The registered manager also had relevant experience within the sector. Leaders demonstrated a passion for the service and the people who use it.

Leaders had a good understanding of the services they managed. They were aware of service performance and aware of challenges faced by the service. They collaborated with one another and other staff to develop solutions or mitigations and were supported by management at provider level.

Staff felt supported by managers and told us that they were approachable and engaged well with them. Leaders were visible within the service and had the experience, capacity, capability, and integrity to ensure that the organisational vision could be delivered, and risks were well managed.

Leadership training was available for staff who wanted to work in a leadership role. There was also training available for staff who already worked in leadership roles. Leaders attended leadership team days to support their leadership development. Reflective practice was built into the service’s meeting structure and was available to all members of staff to promote a supportive culture of development.

The service created a positive culture where people felt that they could speak up and that their voice would be heard.

The service had a freedom to speak up process if staff wished to raise concerns confidentially. Most of the staff we spoke with told us they felt they could raise concerns with managers. Leaders informed us that a whistleblowing procedure was established, and staff were aware of it. Details about the freedom to speak up process was available on posters and had been shared via email.

Leaders told us they wanted to embed a culture of feedback, where people could respectfully challenge and learn. The service had a staff forum which allowed staff representatives to share feedback with leaders of the service. Most staff we spoke with told us there was a culture of openness in the team. Staff told us they felt listened to, and where there was learning this was shared among staff.

People had the opportunity to provide feedback about the service. There were feedback leaflets available for people to complete and people also shared feedback about the service through their key workers or by sending thank you cards. All feedback was collected and monitored by the service. People knew how to raise a concern, and those who had were satisfied by the way it was managed.

The service valued diversity in its workforce. The service worked towards an inclusive and fair culture by improving equality and equity for people who worked for the service.

The service was part of a large provider and had an equality, diversity and inclusion lead. All staff had the opportunity to access and join the LGBTQ+ forum. Leaders told us 125 staff members used the forum. The provider completed a self-evaluation report in March 2025 about how well it supported staff who menstruated. The average overall score was 62 out of a possible score of 75, which was 82.6%.

Leaders put reasonable adjustments in place for staff members to help them carry out their role. Staff completed inclusion passports which supported their individual needs to be met.

The service employed a diverse team of staff from international backgrounds. Employment practices promoted equality of opportunity. The service’s equality, diversity and inclusion action plan demonstrated that the service sought candidates from underrepresented backgrounds. The service had an equality, diversity and inclusion champion based at the Ipswich hub.

Leaders supported 3 staff members per year to carry out additional equality, diversity and inclusion training which included modules such as disability inclusion in practice, neurodiversity inclusion in practice and LGBTQ+ inclusion modules. Additionally, leaders allocated 2 staff members to complete a Level 2 accredited short course on equality and diversity in the workplace. This commitment was made as part of the service’s social value. The service commissioned some training on creating an anti-racist and culturally competent service. The training included discussions about racism in the workplace, culture and how to improve anti-racist practice.

Staff were able to apply to work flexibly. The service had a flexible working policy and staff could complete a flexible working application if they wanted to change their working pattern. The service provided evidence that 9 members of staff successfully applied to increase or reduce their hours over the last year. However, we were told during the inspection that it was difficult to grant some requests if people wanted to reduce their hours due to the staff vacancies within the service.

The service had clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. The service acted on the best information about risk, performance and outcomes, and they shared this securely with others when appropriate.

Meetings at team and management level followed a clear structure to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Clinical governance meetings discussed multiple topics including safeguarding, service performance, incidents and training. Actions were documented and detailed how information was shared with the wider staff group. Cases were discussed in clinical team meetings and multi-disciplinary team meetings with actions documented. The meeting structure followed by the service was a rolling programme which included regular reflective practice sessions, planning and pathway meetings, learning sessions and group supervision. Leaders attended monthly leadership meetings. They enabled service leaders to share information at provider level as well as disseminate information among the service teams.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. Staff participated in mortality and morbidity meetings, which reviewed cases where there had been deaths. The meetings were focussed around learning, identified actions and changes in practice where appropriate, as well as information to communicate with staff.

Leaders maintained and had access to a risk register which included appropriate risks and actions in place to mitigate them. The risks were allocated to an individual and reviewed regularly. Progress was monitored on a regular basis. The risks identified were rated by their severity. Issues raised by staff matched what was on the risk register.

Staff undertook local audits. The audits were sufficient to provide assurance and staff acted on the results when needed. For example, clinical staff completed an audit of the prescription process at all sites. The audit results provided assurance around the safety of prescription processes. Any areas that required further evidence or action were clearly documented. Staff also participated in national audits at provider level.

Leaders had access to information to support them with their management role. This included information on the performance of the service, staffing and service user care. Leaders collected and reviewed data to monitor the performance of the service. The service collected data on successful completions of treatment by pathway, waiting times for treatment and numbers of people in structured treatment. These performance measures were presented on a dashboard. The service had key performance indicators (KPI) set by their commissioners to help monitor and improve progress in performance. Service performance, staffing and the risk register were discussed in clinical governance meetings. Leaders had access to information which ensured they had oversight of risk and performance.

The service had plans for emergencies – for example, adverse weather or an outbreak of illness. The service had a business continuity plan in place for all 3 locations. The plans identified the process to be followed in the event of a number of different emergency scenarios. Leaders described an example where they had tested their business continuity plan in relation to their IT system.

The service had a public health and substance misuse governance manual which set out all the governance structures and processes at service and provider level. This provided staff with a clear guide on the tasks they were accountable for and how those tasks fit into the organisation as a whole.

The service understood its duty to collaborate and work in partnership, so services worked seamlessly for people. The service shared information and learning with partners and collaborated for improvement.

Leaders worked with local partners to promote equality, diversity and inclusion throughout the service. The service worked with multiple local agencies to share information about harm reduction to promote safety for people in the community. Leaders also promoted and provided training to local partners to improve knowledge and collaborative working.Following this work, naloxone was held by several external agencies and they had all been educated on how to use it.

Staff and leaders collaborated effectively with a wide range of external stakeholders, such as commissioners, service delivery partners, statutory agencies, voluntary and community organisations. Staff and leaders continued to build positive working relationships to benefit people who used the service. For example, some staff were able to directly access certain information held by the local council.

Feedback received from stakeholders was positive and highlighted the impact the service has had on engagement in treatment and improved care pathways. Stakeholders reported strong working relationships that have assisted them to jointly tackle issues and make improvements.

The provider held a national Safer Lives conference annually over the last 3 years. The most recent conference took place in November 2024 and involved partners, other providers and those directly impacted by drug use. The purpose was to share best practice and work with other organisations to help reduce harm from drug overdoses and reduce drug related deaths.

The service actively worked to support the local community and promote recovery. The service had access to a recovery grant. This was a specific resource that could be used to support recovery based activities in the local area. People from the community could place a bid for a project that would enhance the local community. Leaders provided a number of examples where the recovery grant had been used, including music events and art groups. These activities were all formed using the recovery grant and the groups continued to use the grant to grow and develop further.

The service was part of a steering group that ran an annual talent event in partnership with another local organisation. The event involved a panel of judges which included a local member of parliament and a celebrity. The event was popular with those in recovery who wanted to demonstrate their skills and talents. The success of the event was reported on in the local media. Staff described it as an emotional and empowering event with people sharing their personal stories. Peer mentors we spoke with told us about the positive impact it has had on them and people who use the service.

The service focussed on continuous learning, innovation and improvement across the organisation and the local system. The service encouraged creative ways of delivering equality of experience, outcome and quality of life for people. The service actively contributed to safe, effective practice and research.

Leaders continually sought to make improvements to the service to benefit people and improve their safety. At the time of the inspection the service launched a ‘click and deliver’ service. This was a free service where people could order naloxone to be sent to their home address. The service was an early adopter in using this initiative. It was available to anyone in the local community; they did not have to be known to the service.

Leaders told us that they committed to plant a tree in the local area for each new person who started treatment. This was to recognise that starting treatment was a big step in someone’s recovery journey. People were given a certificate to acknowledge that a tree had been planted for them. Leaders also told us that one of their ambitions was to become carbon neutral in the future and they were conscious of their carbon footprint.

The service worked with local universities to support psychology students through their training. Psychology staff also guest lectured at local universities which enabled them to promote the service as a potential place to work. Students carried out service based projects. For example, one psychology student completed a review of the needs of female service users. The findings were reported to service leaders, and led to a review of pathway and planning meetings and an action plan was implemented. Staff and leaders were aware of the benefits of working with a vision of service sustainability, by educating university students about working in or alongside substance misuse services in the future.

The service held an annual awards night to celebrate people’s achievements based on the service’s values. The awards night was initially only for staff, however it since expanded to include the achievements of people who use the service and peer mentors. The awards night was described as an emotional event celebrating people’s individual achievements and progress through the service.

The service was shortlisted for a local government award in 2024 for their impactful work with the local council in increasing the number of people successfully completing substance use treatment.