You are here

STARS Southend Requires improvement Also known as Change, Grow, Live


Inspection carried out on 2 July 2019

During a routine inspection

We rated STARS Southend as requires improvement because:

  • Managers did not have sufficiently robust and effective governance systems in place to effectively monitor and have oversight to manage the service, including: a lack of ligature and environmental assessments, maintenance issues and repairs, completion of physical health monitoring and safeguarding practices.
  • Staff informed us that nurses monitored detoxing clients’ physical health. However, we found in six out of nine records, staff did not record physical health monitoring for clients going through an alcohol detox.
  • Staff did not keep an accessible record of safeguarding concerns that did not meet the safeguarding threshold.
  • Staff did not always document safeguarding risks in risk management plans.
  • Some members of staff could not recall any incidents or evidence any learning. Managers did not invite recovery champions to meetings where staff and managers discussed lessons learned.
  • Staff did not report all incidents on the provider’s electronic reporting system, for example finding drugs or alcohol on the premises.
  • The service leaders did not adequately assess the premises or mitigate risks within the environment to ensure client safety. Staff had not completed a risk assessment to identify ligature points and staff failed to identify sash windows on the upper floor that opened fully, as a potential risk of falls.
  • Staff did not check the fridge and freezer temperature where they stored donated food, including meat, for clients’ meals. This increased the risk of food poisoning to clients and staff.


  • Staff took a holistic and collaborative approach to assessing, planning and delivering care and treatment to clients.
  • The service had strong leadership and positive regard for staff wellbeing. Staff felt valued and fully supported by managers within the service and spoke highly of the culture.
  • Despite National Institute of Health and Care and Excellence guidelines stating that clients should have their ECG monitored when being prescribed over 100mg of methadone, nurses demonstrated person-centred and safe practice by lowering this threshold to 80mg of methadone.
  • The service psychiatrist monitored additional health needs and diagnosed disorders to clients that hadn’t received a diagnosis. Commissioners, GPs and external organisations commended the work of the doctor particularly with mental health.
  • The service offered free, hot meals to clients using donated food from restaurants and supermarkets. The service also operated an open-door policy for clients to socialise with their peers even if they were not attending a group.