We are With You Wigan and Leigh

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 good. At this assessment the rating has remained good.

This meant people were safe and protected from avoidable harm.

Clients generally had risk assessments that were comprehensive, regularly reviewed and up-to date. Staff were aware of individual client risks and how these should be managed.

There were mostly effective systems and processes to protect people from abuse and neglect. Staff understood how to protect patients from abuse.

However, we identified issues with recording in relation to monitoring paperwork for blank controlled drug stationary, predominantly at the Wigan location, which included some missing signatures and some concerns about staff practice including writing "as above" and using correction fluid.

This service scored 66 (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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had no serious incidents in the 12 months prior to the assessment.

Staff knew what incidents to report and how to report them. The service used an electronic reporting system. Staff reported all incidents that they should report. Managers reviewed each incident and identified where learning or additional actions may be required.

Staff received feedback from investigation of incidents. Managers were preparing for an upcoming service meeting in August and were identifying key learning to share and discuss with staff at this meeting.

Managers understood the duty of candour. They were open and transparent and gave clients and families a full explanation if and when things went wrong. There had been no incidents which had met the threshold for the duty of candour in the 12 months prior to the assessment.

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.

The service’s first point of access was the prevention engagement team. The focus of this team was engaging with the client at the point of referral. The service aimed for all referred clients to be assessed within 5 days of referral. This assessment informed the next stage of treatment for the client dependent on their needs.

Managers noted that the service would always try to make sure an offer was in place for every client that came through the service.

The service had a process to follow if clients did not engage with the service, which could include follow up via text messages, emails and home visits.

The service did not have a waiting list and there were no exclusions or restrictions on someone using the service. Managers noted that with the prevention engagement team in place it was easier and quicker for referrals to be processed.

If a client’s substance misuse needs were a secondary factor, then the service would link in with the appropriate service, such as a mental health team. Managers advised that staff always ensured a full plan was in place for clients before discharge.

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 would have an exit plan and strategy for each client being discharged and ensuring that the client had all relevant information should they need to come back to the service. The service had options for aftercare that clients could access, including working as a volunteer or attending the service’s 12-week community rehabilitation programme. Managers noted that clients were kept on the system for 6 months post discharge and that check-ins were undertaken with clients.

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 received training in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Staff were trained in safeguarding adults and safeguarding children. At the time of the assessment, the compliance rates for safeguarding adult training was 73.7% whilst the compliance for safeguarding children training was 75.25%. The remaining staff were either in their 3-month refresh window period for the training or were new starters who were in progress with the training, meaning they were not considered to be non-compliant.

The service had a safeguarding manager who was also the safeguarding lead for the service. The safeguarding manager attended external meetings in relation to safeguarding and had oversight of these processes for the service.

The service was using safeguarding tags on their electronic client record system to monitor and have oversight of any safeguarding issues. This enabled managers to access reports of all clients with a safeguarding tag on their record. Managers explained that it would be expected that all clients with the safeguarding tag on each worker’s caseload would be discussed when they had supervision.

Managers had identified that staff would benefit from additional training around professional curiosity and were in the process of arranging for this training to take place.

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 13 client records during the assessment. Clients generally had risk assessments that were comprehensive, regularly reviewed and up-to date. We reviewed one record which did not indicate that risk and behaviour analysis was being undertaken and where there was limited evidence of the staff member asking appropriate questions.

Staff routinely and regularly provided clients with harm minimisation advice in relation to the risks associated with their continued drug and alcohol misuse and safety planning was an integral part of recovery plans.

The service utilised exit plans and strategies for each client being discharged and ensuring that the client had all relevant information should they need to come back to the service.

The service had a process to follow if clients did not engage with the service, which could include follow up via text messages, emails and home visits. Staff gave examples of how they managed clients who may not be engaging appropriately or at risk of disengaging.

Staff involved clients in care planning and risk assessment. We saw evidence of this within the client records that we reviewed. Clients that we spoke to felt involved in their care and treatment.

Staff communicated with clients so that they understood their care and treatment, including finding effective ways to communicate with clients with communication difficulties. Staff could give examples of how they had helped clients to understand their care and treatment.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Staff had not undertaken regular assessments of the environment as expected by the service.

The service had two locations at Coops Business Centre in Wigan and Kennedy House in Leigh. Both buildings were owned and operated by the local authority who had responsibility for all maintenance services as the landlord.

The service did have certain responsibilities in relation to the environment and safety of the buildings which it was expected that staff would complete. We identified gaps in some of these checks.

Both locations had panic buttons in the 1:1 rooms used by staff. We reviewed documentation relating to the testing of the panic alarm systems. For the Leigh location, the last recorded tests were dated 12 July 2024. For Wigan, a small amount of the alarms had been tested on the 02 & 03 July 2025, however, prior to that the most recent tests were dated 12 September 2024. The Facilities Lead confirmed that these checks should be carried out by operational staff and the expectation would be that these be tested monthly, with all alarms being tested across each month.

The organisation also had monthly environmental checks which operational staff were expected to undertake. The most recent version for the Wigan location was saved as the 05 May 2025, although the date on the form itself was 11 April 2025. It also appeared that the February and March checks were not present either. For Leigh, the most recent check was saved as May, although the date on the form was 17 March 2025.

The Wigan location was a significantly larger building across multiple floors and a large reception area. The Leigh location was a smaller building and had a more compact reception area, although there was space for multiple clients. Both locations generally had adequate space and staff were present as needed.

The service generally made sure there were enough qualified, skilled and experienced staff, although some staff raised concerns about caseload numbers and turnover rates within the service. Staff worked together well to provide safe care that met people’s individual needs.

In the 12 months prior to the assessment, the service had an average sickness rate of 7.1% and an average turnover rate of 26.4%. Managers noted that they were liaising with the organisation’s learning and development team around the higher turnover levels, to consider how staff coming in to the service may be better supported during this process. Managers also stated that the turnover rate was impacted by staff leaving for other job opportunities and was a similar theme being seen across the sector.

Managers supported staff who needed time off for ill health. Staff gave positive feedback about how managers had supported them through ill health or personal issues.

The service had low numbers of vacancies at the time of the assessment, including one pharmacy technician, one nurse medical prescriber and two team leaders. The service had recently recruited to 5 recovery worker positions and these staff were in the process of being onboarded.

The service generally had enough nursing and support staff to keep clients safe. Staff gave mixed feedback about caseload numbers in particular at Wigan where it was noted there appeared to be a higher turnover of staff which meant caseloads could often increase unexpectedly when a staff member left. Some staff felt this was not always managed well, however, other staff felt this was not an issue and that they could manage their caseloads safely. Managers advised that they were currently undertaking a piece of work around caseloads and the weighting of these at the time of the assessment. Managers were due to engage staff with this process to review how caseloads could be managed more effectively.

The service was using agency staff at the time of the assessment to support the ongoing work and ensure that the service had the resources to meet the demand and needs of clients.

Staff were up to date with mandatory training. The service provided a training compliance report which separated the staff into existing staff (those in post for over 12 months), and new starters (those who had been in post less than 12 months). The service gave existing staff a 3-month refresh window period during which they must attain compliance. At the time of the assessment, the overall completion rate for existing staff was 71.8% with 28.2% of staff in the refresh window. The overall completion rate for new starters was higher at 79.5% and 20.5% in progress. No members of staff were considered as being non complaint with their mandatory training at the time of the assessment. The provider had a mandatory training target of 90%.

Managers recruited, trained and supported volunteers to work with clients in the service. The service had a volunteer co-ordinator and a national volunteer lead. All volunteers would have an induction period and would be allocated a buddy to support with their development learning. The service had a volunteer database for oversight and assurance. Managers noted that, for quarter 1 of the current year, volunteers had worked 180 hours within the service.

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.

The two services were generally clean although some of the carpeting at the Wigan service in particular was a bit worn and had some staining in places. The cleaning of the two services was managed by the local council.

We reviewed the clinic areas for both services which were generally clean and tidy. The facilities manager noted that some improvements were still to be made in the clinic areas at the Leigh location, such as replacing the cork noticeboards with noticeboards that could easily be wiped down to aid with managing infection prevention and control.

The service did not always make sure that practices, recording and oversight in relation to prescriptions were always safe .

Staff were not always following good practice in relation to their recording of monitoring paperwork for blank controlled drug stationary or in terms of having oversight of this process.

We reviewed monitoring paperwork at both locations and identified, predominantly at Wigan, missing counter signatures and poor practice being used when recording. This was in relation to the handling of FP10 controlled drug stationary.

At Wigan, multiple examples of missing counter signatures were identified on the prescription order and receipt log; with paper records being reviewed back to February 2025 and a record from 04 February 25 was identified as having a missing signature. A sample of records was also reviewed at the Leigh location where similar issues were identified but on a much lower scale. These did not relate to completed prescription forms and were not a direct risk to client safety.

The records also indicated poor practice being used by staff when recording and signing, such as using the “as above” symbol in place of using their full signatures along with examples of correction fluid being used instead of crossing over the mistake and countersigning. The use of correction fluid was on multiple records at Wigan and in one of the records at Leigh. The medications management audit for Leigh in 2025 had identified that FP10 handling documents were not being completed correctly, although it had not been identified in the audit for the Wigan service. We were not assured that the audits were therefore being completed as thoroughly and effectively as they should have been.

Following the on-site assessment, the provider confirmed that the organisation’s Central Medicines Management team sent guidance to the service and the wider organisation regarding the need for full signatures, proper witnessing and the inappropriate use of correction fluid on all documents, not just when logging the movement of FP10 stationary. They also noted that the Clinical Leads had added regular audits to their calendars to monitor and have oversight of these issues.

The service risk register included a risk of overdue clinical reviews for clients. The service confirmed that this was in relation to the organisation’s ‘gold standard’ target of the frequency of reviews, which exceeded the minimum requirements within national guidance. Managers had identified actions to address this issue and ensure that they had appropriate oversight of it. Managers noted that the numbers of overdue reviews were gradually decreasing.