Archived: CGL Manchester

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 Requires Improvement. At this assessment the rating has remained Requires Improvement.

Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of regulation for staffing. Staff did not receive the required training for their role and there was no clear oversight of inductions for new staff in all roles.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

• The service had no serious incidents in the last 12 months. However there had been several deaths of clients within the community, that the service had been made aware of by other services and organisations.
• The service had created a process for staff to follow when involved in a violent incident. The process included who to report the incident to, timescales and the support that should be provided for staff
• The service had an incident management procedure which included incident reporting on the electronic record system.
• All staff knew what incidents to report and how to report them.
• Staff reported all incidents that they should report. These were also discussed at the daily morning FLASH meetings (meetings to handover information and plan logistics for the team including health and safety roles and allocations).
• Staff understood the duty of candour. They were open and transparent, and gave clients and families a full explanation if and when things went wrong.
• Staff received feedback from investigation of incidents, both internal and external to the service. Monthly learning from death review bulletins were created and shared with staff, these included good practice and areas of learning.
• An average of bi-monthly team meetings took place to share updates in harm reduction and learning from death reviews. Monthly death review meetings took place. Minutes showed staff presented case summaries of clients that had died including sharing good practice and learning for the service.
• There was evidence that changes had been made as a result of feedback. Records showed that a staff member had been changed for a client following feedback about the gender of the staff member and previous trauma the person had experienced. The service facilitated this to enable an improved working relationship.
• Staff were debriefed and received support after a serious incident. There was also a psychology team who provided opportunities for reflective practice.

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

• The service’s referral and admission processes ensured that all essential information about each client was received to determine if the client’s needs could safely be met. There was an intervention team, with intervention workers who triaged all referrals, made contact over the phone to gather information and explored the support available. The interventions teams were also available in bases for people to drop in, to be assessed. Interventions workers could also offer brief interventions if people were not ready for or did not need structured treatment.
• Staff involved all the necessary healthcare and social care services to ensure clients had continuity of safe care, both within the service and post-discharge. The service worked closely with other services including housing, mental health services and detoxification services. Records showed liaison with other services to share information for the benefit of clients.

We do not always work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people's lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

• Staff were trained in safeguarding, with 99% compliance. Staff knew how to make a safeguarding alert, and did that when appropriate. However there was no process in place to enable oversight of the number of alerts that the service had made.
• The electronic care record was repetitive in relation to safeguarding, with staff having to record their safeguarding actions in several places, including sharing information to and from other agencies, referrals and children and families sections. This meant staff could miss sections of the system due to the duplication. Staff also used the system differently and would record their safeguarding actions in different sections.
• Designated safeguarding leads were in post and were usually at team leader level. Their role included giving advice and guidance to staff and attending external meetings including MARAC (Multi agency risk assessment conferences), to discuss people in high risk domestic abuse situations.
• The services provided safe storage boxes for medicines, especially when there were children in the home.
• Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.

We always work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

• We reviewed 28 care records during the assessment and found that 26 records had risk assessments that were up to date.
• We reviewed the care record system which showed care records tuned red when items were out of date, this information was collated in a report, which we reviewed. There were 22 care records overdue for a risk review out of 2818 records as of 18 June 2025, this was less than 1%.
• Staff tried to involve clients in care planning and risk assessment. Records showed, and clients told us, that they were included in discussions about their treatment options.
• Staff communicated with clients so that they understood their care and treatment, including finding effective ways to communicate with clients with communication difficulties. We saw treatment leaflets in languages other than English and a drinks diary with pictures of the drinks.
• Staff enabled clients to give feedback on the service they received via surveys and consultations. Findings were displayed as ‘we asked, you said’.

We do not always detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

• Risk assessments were completed for all the bases. The Bradnor Point risk assessment included ligature risks, however the risk assessments for the other 4 bases did not include these risks, this meant the assessments were not consistent across the bases.
• We reviewed the pending and outstanding maintenance requests for the locations and found they did not fully reflect what we saw. The group room at Zion Centre had dirty patio doors behind the shutters, missing flooring, ill-fitting cupboard doors and water damage in the cupboard wood work which had not been reported as a maintenance request. This meant action could not be taken to resolve these issues, if they were not reported.
• Staff had access to alarms in interview rooms. However, not all staff were aware of these at the Zion Centre. This meant not all staff were aware of how to keep themselves safe and summon assistance from these rooms if needed.
• Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. Emergency medicines included Naloxone, a medicine used to rapidly reverse opioid overdoses.

We do not make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

• The service had 17 vacancies which equated to 8%. There had been 29 staff leaving the service in the last 12 months, which equated to 13%. Staff sickness rate for the last 12 months averaged at 5%. The service had been using 10 agency staff in July 2024 (10%), this had reduced to 2 agency staff in June 2025 (1%).
• When necessary, managers deployed agency staff to maintain safe staffing levels.
• We reviewed the induction processes for new staff and found that there were induction workbooks and checklists in place for recovery coordinators and leaders. However there were no workbooks and checklists for intervention workers, lived experience mentors and agency staff. This meant the service could not be assured that all new staff had received the necessary information for their role. We reviewed 3 induction processes for 3 new staff and found a recovery coordinator had a checklist signed however there were no completion dates included. This meant the service did not know when they were inducted into the service. The intervention worker had a timetable of their induction including shadowing opportunities and eLearning however there was no workbook or checklist of areas to cover during the induction to ensure consistency. The lived experience mentor had a record of the training they had completed, however no workbook, checklist or detailed timetable of their induction recorded, this meant new staff were not all receiving consistent information and the induction did not include lone working guidance or information specific to the building they were based in.
• We reviewed the caseloads for staff at Carnarvon Street and found the highest caseload was 85 clients, then 10 staff with over 60 clients on their caseload. Records showed, and staff told us, that new staff had joined the teams and they would be reallocated some of the clients from colleagues with a higher caseload. Staff told us if colleagues were off for more than 4 weeks, their caseloads would be redistributed amongst the team, and this was stressful to try to see clients as frequently. Staff told us caseloads of over 60 clients could be stressful as it was hard to keep on top of the actions they needed to complete for this many clients.
• Staff had not received and were not up to date with appropriate mandatory training. Learning Disability and Autism training was not listed as a mandatory training course. This meant the service were not fully meeting the requirement from the Health and Care Act 2022. Since 1 July 2022, all registered health and social care providers have been required to provide training for their staff in learning disability and autism, relevant to their role, including how to interact appropriately with autistic people and people who have a learning disability. The training levels were 39% for an autism awareness workshop and 38% for learning disability and autism eLearning training. The training which was mandatory was equality and diversity, Mental Capacity Act and Deprivation of Liberty Safeguards, safeguarding adults and children, display screen equipment, introduction to health and safety and data protection and information security.
• The training was not appropriate for the client group using the service. There was no mandatory training in relation to substance misuse and related topics. Related training was available for staff, however there was low compliance for this: Naloxone 55%, Blood Borne Virus screening 42%, Needle Exchange 53%, Challenging situations 21%, Introduction to Opioid Substitution Treatment 19%, Introduction to Drug and Alcohol Awareness 17%. When exploring safety for staff, in addition to alarms in interview rooms, we were told of the first responder role, where if alarms were raised, staff were allocated to be first responders. Staff told us they were reluctant to do this role as they had not received training and did not feel confident. We reviewed the training figures and found the first responder virtual session had 13% compliance, first responder Managing Positive Behaviour Programme curriculum had 9% compliance and first responder Managing Positive Behaviour Programme in person training had 9% compliance. This meant staff had not been provided with training on how to respond safely in difficult situations.

We do not always assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

• Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.
• Not all rooms used by the service were maintained to a high standard. At Carnarvon Street, there was an interview room with staining on the walls from leaks. At the Zion Centre there was a section of the floor covering missing, the units had water/damp damage and the patio doors behind the shutter was dirty. This meant that there was a risk of cross contamination as not all surfaces could be cleaned to a high standard.
• Staff did not always adhere to infection control principles. We saw nurses that were not bare below the elbow, with cardigans and watches on. This meant not all staff were following National Institute of Health and Care Excellence Guidance: Healthcare-associated infections: prevention and control in primary and community care Clinical guideline: CG139.This guidance aims to reduce the risk of healthcare-associated infections.

We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

• Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did this in line with national guidance.
• The service held Naloxone, a medicine used to rapidly reverse opioid overdoses. This medicine was offered to clients, with training provided on how to administer this. However, the staff compliance rate was 31%. The service also promoted the stock of this medicine with other providers and offered them training in how to administer the medicine, this included day centres and hostels for people sleeping rough or in temporary accommodation. Sharps bins were also provided by the service for safe disposal of needles.
• Clients were offered safe storage boxes to store their medicine, particularly if they had children in the home, to safeguard against accidental ingestion.