Stockton Recovery Service

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

At our last inspection we rated this key question good. At this inspection the rating has remained good. This meant people’s needs were met through good organisation and delivery.

Staff managed access and flow well. The design, layout, and furnishings of the service’s premises supported clients’ treatment, privacy, and dignity. Staff supported clients with activities outside the service, such as work, education, and family relationships. The service met the needs of all clients – including those with a protected characteristic. Staff helped clients with communication, advocacy, and cultural and spiritual support. The service treated concerns and complaints seriously, investigated them and learned lessons from the result.

We have not awarded this service a score for Responsive.

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

We scored the service as 3. The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Staff based client care around individual needs and preferences. Staff prescribed sugar-free methadone as an alternative to the regular type for clients with diabetes. Staff told us they could arrange for changes to medicine collection times at pharmacies for clients of the Muslim faith who were observing Ramadan. Staff also arranged to meet people with mobility issues within the community as opposed to the service building.

We saw evidence in care records that decisions around care and treatment were made in co-creation with the client and their carers where appropriate. We saw evidence that staff discussed discharge with clients when they were near the end of their recovery journey.

Care plans reflected the strengths and goals of clients and included actions to develop their recovery capital. Clients and a carer told us that they had worked in partnership with staff to create structured treatment plans, care plans and relapse plans. They also commented that the service’s consent and confidentiality procedures were good and they were involved in decisions about their care and treatment.

Staff provided carers with clear information for supporting themselves and their loved ones. For example, a carer we spoke with told us they were kept informed and updated regularly about their daughter’s progress.

We scored the service as 4. The evidence showed an exceptional standard. The service had an exceptional understanding of the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Staff within the service provided coordinated care that supported continuity through strong partnership working, clearly defined referral pathways, and integrated delivery with local services. Care plans were used to identify individual needs and guide referrals, ensuring people received tailored support across a range of health, social care, housing, criminal justice, and education, training and employment services.

Where a person’s needs could not be fully met by the service, clear referral pathways were in place to ensure timely access to appropriate support. Referrals were identified through assessment and ongoing review and were linked to care plans to ensure coordinated and consistent care.

The service had well-established links across primary care, secondary care, social care, housing, and criminal justice services, enabling people to move seamlessly between services depending on their needs, with shared care planning and clear escalation routes.

Where mental health needs were identified, cases were reviewed through multidisciplinary triage involving psychology, dual diagnosis leads, and partner services, with shared decision-making to appropriate internal or external provision.

A weekly Fibro Scan clinic had been introduced within the service to support early identification of liver disease. A Fibro Scan is a quick, painless, non-invasive ultrasound-like test that measures liver stiffness (to detect scarring or fibrosis) and fat content. It can replace the need for a liver biopsy and takes around 10 minutes to complete.

Pregnant clients were supported through close partnership working with a specialist community midwife, who attended regular pregnancy multidisciplinary team meetings to discuss shared cases. Joint home visits were also undertaken where appropriate, ensuring coordinated care planning and strengthened engagement. This work was supported by oversight from the service’s clinical lead and input from a senior social worker, to ensure that safeguarding, risk management, and care planning were appropriately managed.

Staff supported individuals to maintain and rebuild relationships with people who mattered to them, recognising the importance of social support networks in recovery. Clients were encouraged to consent to involving family members and loved ones in their care and treatment, where appropriate, which helped improve engagement and treatment outcomes. Clients who spoke with us told us staff supported them to maintain contact with their loved ones.

The service worked closely with a locally commissioned carers service. This service signposted family members and loved ones to access their own support.

Staff encouraged and supported clients to access mutual aid groups, and supported individuals to establish ongoing peer support networks beyond the service.

Staff supported clients with opportunities for employment and education through an integrated model, including individual placement and support (IPS) provided by a partner organisation. IPS is an evidence-based approach that supported individuals to gain and sustain employment through personalised support and close integration with treatment teams.

The service worked closely with criminal justice partners to ensure continuity of care for individuals entering or leaving custody. Established pathways supported transitions between community services and prison healthcare teams, with relevant information and care plans shared to maintain engagement and continuity of treatment. When individuals entered custody, care and prescribing information was communicated to prison healthcare services. On release, individuals were supported to engage with the service, which included fast-track appointments to reduce the risk of treatment disruption. Local performance demonstrated the effectiveness of this approach, with continuity of care rates in Stockton at 63%, compared to a national average of 56%, reflecting strong partnership working and consistent follow-through of care.

The service understood local demographics and the diverse needs of the local community.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff made notifications to external bodies as needed such as local authority safeguarding teams and Care Quality Commission. They also submitted National Drug Treatment Monitoring Data (NDTMS) to the Office for Health Improvement and Disparities (OHID) when required.

Information governance systems included confidentiality of client records. Staff needed a username and password to access the service’s care records systems. Staff received training in information governance.

Staff ensured that clients could obtain information on treatments, local services, clients’ rights, how to complain and so on. The information provided was in a form accessible to the particular client group such as easy-read or in different languages.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment, and support. They involved people in decisions about their care and told them what had changed as a result.

There had been 4 complaints in the12 months prior to our inspection, none of which were upheld. There were no themes or trends from these complaints.

Clients we spoke with knew how to complain or raise concerns. Staff had displayed information about the complaints process in the reception area and within other rooms used by clients, and paper feedback forms were readily available in the reception area for people to complete.

Staff protected clients who raised concerns or complaints from discrimination and harassment. Complaints and emerging themes were reviewed as part of a lived experience group, where feedback was discussed and used to identify areas for service improvement. Staff knew how to handle complaints appropriately.

The service ensured stakeholders and other community groups could give feedback about the service and input into service delivery.

Staff provided carers with information about support groups and carers assessments.

Clients had access to and information about advocacy services.

Staff used a range of methods to gather feedback from people who used the service. This included day-to-day conversations, key working sessions, lived experience forums, suggestion opportunities, and a service user pulse survey.

Staff used a “you said, we listened” approach to client feedback, with updates displayed in reception and reviewed quarterly. Examples of improvements made in response to feedback included:

• introducing hot drinks in reception, creating a more supportive and engaging environment
• introducing late evening recovery groups so clients working during the day could access them
• the provision of free Wi-Fi within the building for clients to access.

Staff enabled clients to contribute to decisions both at an individual level and in wider service development. Clients had contributed to the design of pathways, policies, and improvements. During the recruitment of a consultant clinical psychologist, a representative from the local Lived Experience Recovery Organisation (LERO), who brought lived experience expertise, was included on the interview panel. This ensured that lived experience perspectives informed the selection process and contributed to appointing a candidate aligned with the needs of people using the service.

We scored the service as 4. The evidence showed an exceptional standard. The service was exceptional at ensuring people could access the care, support and treatment they needed when they needed it.

Staff ensured the needs of clients with mobility issues were met. For example, we saw there was disabled toilets and step-free access.

The service’s website was designed to be usable by a wide range of people, including the ability to adjust fonts and contrast, zoom up to 300%, navigate using a keyboard or speech recognition software, and use screen readers.

Staff made reasonable adjustments for clients. Examples included:

• Flexible appointment times and alternative group provision, including evening sessions
• Joint home visits for individuals with additional needs such as support for pregnant clients from midwifery services
• Supporting people to complete forms, surveys, or digital processes, including use of a reception kiosk and staff assistance
• Adapting communication methods, including simplified information and additional support where required.

The service ensured accessibility for people with communication and language needs through the use of an interpreting and translation service. This included telephone, video, and face-to-face interpreting, translation of written materials, and access to alternative formats such as large print, Braille, easy read, audio, and accessible digital documents.

There was adequate medical cover, and the service could access support from mental health services.

Staff ensured clients had access to post-discharge care. All clients were offered a structured aftercare plan on completion of treatment, outlining ongoing support needs, relapse prevention strategies, and connections into community provision.

Staff also undertook check-ups of each client at 1, 3, and 6 months post-discharge, providing planned follow-up contact to review progress, offer support, and facilitate re-engagement where needed.

In addition to structured follow-up, clients were also supported to access ongoing recovery and community-based provision as part of their aftercare plan, including:

• Peer-led groups and structured activities
• Mutual aid groups
• Education, training, and employment opportunities through individual placement and support (IPS) and the service’s ambassador programme. The provider's subcontracted partner, ran ambassador programmes that used people's personal lived experience to support local recovery services, mentor peers, and build pathways into employment.

The service was easy to access. Staff planned and managed discharge well and had alternative pathways for people whose needs it could not meet.

The service undertook outreach programmes to groups that may be reluctant to engage or under-represented in treatment, including those experiencing social isolation, stigma, or complex needs. Outreach was supported jointly with the partner organisation, including use of a recovery bus, which improved access for individuals who may not otherwise attend the service.

Targeted health initiatives further supported engagement, including a Hepatitis C micro-elimination drive delivered across hostels and pharmacies, reaching individuals at increased risk who may not access mainstream services.

The service offered flexible delivery to reduce barriers, including online sessions, a daily drop-in offer, and late evening opening, ensuring that individuals who were working or may struggle with structured appointments could still access support in a way that met their needs.

Staff were also working to improve accessibility for neurodiverse people, with clinical leadership and psychology input to assess current provision and implement training to ensure staff were equipped to meet diverse needs.

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support, and treatment in response to this.

Staff within the service and the wider organisation promoted a culture in which the people using the service felt empowered to give their views. All staff were trained in equality, diversity and inclusion.

The provider’s policies, procedures, and any service changes had been subject to equality impact assessments to identify and mitigate any potential barriers or unintended discrimination.

The service took a data-led approach to understanding equity, by routinely collecting and reviewing demographic information for individuals from the point of entry to treatment, and to discharge. This included the analysis of characteristics such as age, ethnicity, disability, and other protected or relevant factors. This data was analysed through local performance dashboards to monitor access, engagement, and outcomes across different groups. By reviewing this information at each stage of the treatment journey, the service was able to identify trends, gaps, or inequalities and respond appropriately.

Flexible delivery models, including online sessions, drop-in access, and late evening provision, had also been implemented in response to identified barriers, ensuring more equitable access and experience.

We saw evidence in care records that staff supported clients to make decisions about their care and treatment and their future. Clients who spoke with us also confirmed that they were routinely involved in decisions about their care and treatment.

Staff created personalised care plans to account for the client’s needs, wishes and feelings.

We saw evidence in care records that staff ensured all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of people with complex needs.

We saw evidence in care records that staff supported clients to create and review relapse plans.