Stockton Recovery Service

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

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.

We scored the service as 4. The evidence showed an exceptional standard. The service had a strong, proactive and positive culture of safety, based on openness and complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

There was 1 serious incident in the 12 months prior to our inspection. The investigation led to service improvements including strengthened safeguarding oversight, reinforced expectations around information sharing and escalation, enhanced reflective supervision discussions, improved recording standards, and continued workforce development relating to safeguarding and complex family risk.

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.

All staff we spoke with knew what incidents to report and how to report them. Staff received feedback from the investigation of incidents, both internal and external to the service. Staff met to discuss that feedback. There was evidence that changes had been made as a result of feedback. Following an increase in abusive behaviour towards staff within the reception area, managers reviewed staffing arrangements and environmental risks. This led to a reconfiguration of the service layout, with the multidisciplinary duty team relocated to reception to improve visibility, oversight, and responsiveness to risk, while administrative staff were moved to a safer environment. A red, amber and green rated guidance system was also introduced to support consistent decision-making and prioritisation of need. These actions improved staff confidence, responsiveness, and overall safety.

Feedback identified that in some higher-risk situations such as changes to prescribing arrangements, clients would benefit from clearer follow-up communication. Whilst clinicians routinely discussed prescribing decisions, recovery coordinators were now able to reinforce this information. Targeted guidance and support were introduced to improve confidence in explaining the rationale for changes, particularly in relation to risk management. This improved consistency of communication, client understanding, and engagement.

Following a serious multi-agency case review, the service strengthened its safeguarding and multi-agency approach. Learning informed the development of a stronger ‘Think Family’ approach, ensuring family networks were included in assessment and support planning. Safe storage agreements were reintroduced, supported by outreach visits to verify safe practice in clients’ homes.

Partnership working with other organisations worked well to verify information and identification of risk.

Governance had been strengthened. Social workers now audited safeguarding cases to ensure reviews reflected the current risk. Multidisciplinary team processes had been adapted to increase partner involvement, including routine attendance from key professionals.

Managers carried out reviews when clients had died. All deaths of people in treatment, or within 6 months of discharge, were subject to a learning from deaths process, ensuring that their care and treatment was reviewed and any lessons were identified.

Managers shared learning from incidents that happened elsewhere such as other services ran by the provider and from other organisations. Learning was shared across teams through established governance structures, with learning from experience reviews included as a standing agenda item within team meetings. This ensured that themes were routinely identified, tracked, and used to inform service improvement and prevent future harm.

The service participated in local drug and alcohol related death panels, working with partners to review deaths and near-fatal overdoses. This supported shared learning, identification of risk patterns, and coordinated action to reduce harm.

The service contributed to a system-wide innovation to reduce drug-related deaths, launched in June 2026 with Not on My Watch and local hostel providers. This included supporting the rollout of a wearable overdose prevention device that alerted emergency services in the event of an overdose. The service identified and engaged high-risk individuals through established hospital and ambulance service pathways. It also ensured that anyone experiencing a non-fatal overdose was supported through the local overdose pathway and escalated for multidisciplinary review where appropriate. This partnership-led approach demonstrated innovative use of technology and data to proactively manage risk and improve safety for vulnerable individuals.

Staff were debriefed and received support after a serious incident. Following a death, staff were provided with opportunities to debrief and reflect, emotional and practical support and clear guidance and structured processes.

We scored the service as 3. The evidence showed a good standard. 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.

The service’s referral and admission processes ensured that all essential information about the client was received to determine if the client’s needs could safely be met. Referrals were accepted through multiple routes including online, telephone, email, and in person via booked appointments or daily drop-in sessions. Referrals were received from a range of partners including primary and secondary care, criminal justice services, housing, social care, as well as self-referral or through family members. Referrers were asked to share relevant risk information at the point of referral to support continuity and safe care planning.

All referrals, including drop-in presentations, were subject to an initial triage process to assess risk, urgency, and suitability. This ensured clients were seen by the right professional, in the right setting, and within appropriate timeframes. High-risk presentations, such as prison releases or hospital discharges, were prioritised for same-day assessment. The average time between referral and triage was 2.4 days.

The service had a dedicated engagement team supported by prescribers, nurses, and social workers, to enable timely risk assessment and escalation. For drop-in clients, a same-day screening was completed to identify immediate risks including safeguarding, substance use, and mental health concerns. Where required, clients were prioritised for urgent assessment or escalated to appropriate emergency or crisis services.

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. Staff sought client consent to share information with partner agencies to support joined-up, holistic care. This enabled effective care planning, continuity of care, risk management, and timely access to interventions such as requesting GP summaries to support same-day prescribing. The service provided pathways into treatment, working in partnership with NHS services to ensure timely access to care. This included referrals for Hepatitis C treatment, and referrals to specialist HIV services for ongoing care and management.

The service worked closely with a wide range of partners including primary and secondary care, social care, criminal justice services, police, housing, and specialist services. Staff participated in multi-agency risk assessment conferences and multi-agency public protection arrangements (MAPPA) meetings. Multi-agency working was embedded within practice to ensure coordinated and safe care delivery. The service was also a key partner in the Domestic Abuse Protection Order (DAPO) pilot programme, working closely with police and domestic abuse prevention services to support risk management, early intervention, and the safety of individuals affected by domestic abuse.

The service had a defined and effective referral pathway in and out of prison, supported by a dedicated criminal justice team, which included a prison link worker. This supported continuity of care for individuals transitioning from custody into the community, achieving a continuity of care rate of 64%, above the national average of 56%.

There were protocols in place for managing clients who presented at the service intoxicated or in crisis. These included dynamic risk assessments, staff support, and escalation pathways. The environment and staffing model included a visible duty team, which supported timely response to risk and safe management of unplanned presentations. This was supported by the provider’s approach to behaviours that challenge; including staff training, and preventative environmental strategies.

Staff planned and managed discharge well. Recovery coordinators completed an aftercare plan with clients, which could include ongoing support from partner services such as housing, education, training and employment, and recovery services. Recovery check-ups were conducted at 1, 3, and 6 months post-discharge to support sustained recovery and enable rapid re-engagement with treatment if required.

The service had alternative care pathways and referral systems for people whose needs it could not meet.

We scored the service as 3. The evidence showed a good standard. 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 were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. At the time of our inspection, all staff had completed their mandatory safeguarding training.

Staff had submitted 28 safeguarding referrals to the local authority in the 12 months prior to our inspection, 20 related to adults and 8 related to children.

Staff we spoke with could give examples of how to protect clients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. When an individual attended the service whilst intoxicated and responsible for a child, this was treated as an immediate safeguarding concern. Staff escalated their concerns to managers within the service, took steps to ensure the child’s immediate safety, and made referrals to the local authority where required.

Staff followed safe procedures for children visiting the service. Children attending the service were recognised as a higher-risk group and were required to remain under the supervision of their parent or carer at all times.

The service ensured that clients (particularly those with children) understood safe storage of medicines at home. We saw evidence in care records that clients had been issued with storage boxes to keep their medicines safely locked away to prevent children from accessing them.

There had been 1 serious case review in the 12 months prior to our inspection and lessons learned from this were used to improve the service.

Mental Capacity Act / Consent to care and treatment

Staff we spoke with had a good understanding of the Mental Capacity Act, in particular the five statutory principles. They were able to identify where mental capacity was a concern in a client consenting to treatment. All staff were up-to-date with their Mental Capacity Act training.

We saw evidence in care records that staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.

Staff took all practical steps to enable clients to make their own decisions. When clients lacked capacity, staff involved mental health services and made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

Staff ensured clients had agreed and signed consent to treatment forms and they were accessible to all staff involved in the client’s care and treatment.

Staff ensured clients had agreed and signed confidentiality agreements in relation to who staff could share their personal information with and they were accessible to all staff involved in the client’s care and treatment.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to clients 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.

We reviewed 10 clients’ care records during our inspection. All records reviewed had comprehensive risk assessments completed. Identified risks included risks in relation to substance misuse, risk in relation to self, staff and others and any mental health issues. Risk management plans included harm minimisation advice, details of whether the client had access to naloxone, safer use advice and protective factors such as being placed on supervised consumption of substitute medicine and interventions from mental health services.

Staff created re-engagement plans for all clients which included steps to take if the client unexpectedly dropped out of treatment.

The service had a process in place for what to do when there were suspicions or evidence that a client had passed on their substitute medicine to a third party for illicit purposes (an act commonly known as ‘diversion’).

Staff encouraged clients on medicine collection regimes to take lockable storage boxes in which to keep their medicines to safeguard any children or vulnerable people living with them.

The service’s list of banned items for clients visiting its premises was in line with those expected for a substance misuse service such as the possession of bladed articles and weapons, drugs and alcohol.

We saw evidence in care records that staff involved clients in care planning and risk assessment. Clients who spoke with us also confirmed they were involved in decisions about their care and treatment.

Clients told us that staff communicated with them so that they understood their care and treatment. Staff found effective ways to communicate with clients with communication difficulties such as the use of interpreters, signers and provision of information in different languages or easy read.

Staff ensured that clients could access advocacy.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Quality Statement Score: 3

Staff completed and regularly updated thorough risk assessments of all areas and removed or reduced any risks they identified.

All interview rooms had alarms and staff available to respond. All clinic rooms had the necessary equipment.

All areas were clean, well maintained, well-furnished and fit for purpose. Staff made sure cleaning records were up-to-date and the premises were clean.

Staff followed infection control guidelines, including handwashing. Staff made sure equipment was well maintained, clean and in working order.

The reception areas were managed safely with adequate space and alarms in place.

We scored the service as 3. The evidence showed a good standard. The service made sure 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.

The service had enough staff to keep clients safe and caseload numbers were not so high that adequate support could not be offered. Staffing included a range of clinical and non-clinical staff to meet clients’ needs including: a doctor, detox and rehabilitation workers, recovery workers, nurses, rough sleeper worker and social workers as well as other roles.

The service was recruiting to 2 new roles that had been created; 1 WTE children and young people early intervention coordinator and a 0.6 WTE nurse.

The average staff turnover in the 12 months prior to our inspection was 19%. The reasons for staff leaving included seeking alternative employment, family commitments, ill health, career progression, end of a fixed-term contract and other personal reasons. There was also 1 death in service and 1 withdrawn appointment prior to the person commencing work at the service.

Managers determined staffing levels using local population need, contract requirements, and benchmarking against comparable services. The provider had established workforce modelling tools and calculators for recovery coordinators, prescribers, and nursing staff, Staffing was also determined by local data including caseload size, complexity, and the number of individuals in structured and prescribed treatment. Staffing levels were adjusted based on risk, complexity and service demand. Any staff absences were covered within the team.

Staff had received and were up to date with appropriate mandatory training. At the time of our inspection, the overall compliance rate was 99%. The training was appropriate for the client group using the service. Training included:

• Health and safety
• Basic life support and anaphylaxis
• Safeguarding
• Equality, diversity and inclusion
• Learning disabilities and autism
• Mental Capacity Act and Deprivation of Liberty Safeguards
• Risk identification and mitigation
• Assessment and care planning.

Managers supported staff who needed time off for ill health. The average staff sickness absence in the 12 months prior to our inspection was 6%.

Managers ensured all staff employed to work with clients had up-to-date Disclosure and Barring Service (DBS) certificates in place and there was a process for reviewing these.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

All areas were clean, had good furnishings and were well-maintained. Cleaning records were up to date and demonstrated that the areas were cleaned regularly. Staff maintained equipment well and kept it clean.

Staff adhered to infection control principles, including handwashing and the safe and appropriate disposal of clinical waste. Staff completed infection control audits and acted on any areas for improvement they identified. Staff within the service ensured the safe storage of sharps and used needles.

Clinical areas had the required standard of cleanliness for clients to have thorough physical examinations, including areas for blood borne virus (BBV) testing and urine screening.

We scored the service as 3. The evidence showed a good standard. 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.

Staff followed best practice guidance before prescribing and a full assessment was completed including physical health checks. Non-medical prescribers worked within the National Institute for Health and Care Excellence (NICE) guidance and legislation. Staff requested a GP summary before initiating prescribing. Where clients were not registered with a GP, local GP practices agreed to accept new patients.

People were given information on the treatments available and consent was obtained. Staff reviewed clients' medicines regularly and provided specific advice to clients and carers about their medicines.

Staff ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines.

Prescription pads were stored securely in line with national guidance, and a record was kept of serial numbers when they were issued to prescribers. The service also kept a log of when prescriptions were destroyed such as when a client’s treatment changed. These prescriptions were entered onto a prescription log, and a second person witnessed the destruction. Any lost prescriptions or uncollected prescriptions were discussed with the clinical team.

A clear rationale was in place where changes to pick-up regimes were made with a clear and effective risk assessment and documentation. Staff assessed all clients for safe storage of medicines. When necessary, clients were given a lockable box in which to store their medicine as a safety measure. The service worked closely with the local pharmacies providing the pick-up service around changes to prescriptions and through a daily missed-dose report when clients failed to pick-up doses.

Clinic rooms were clean and tidy. Appropriate equipment was in place, and equipment had been calibrated. Vaccines held by the service for the treatment of blood borne infections were stored in a fridge and were kept safely. Records of fridge temperature were recorded daily in line with national guidance. The expiry dates of these vaccines and emergency medicines for anaphylaxis and overdose were date checked regularly ensuring that they were safe to use. A defibrillator was available. Naloxone for the treatment of overdose was kept as an emergency medicine and the quantity available had been recently increased in response to learning from an incident. Family members of clients were offered training and a supply of naloxone for emergency use.

The service had systems to ensure staff knew about safety alerts and incidents, so clients received their medicines safely. There was an internal system for reporting near misses for the purpose of learning.