CGL Peterborough Aspire

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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 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.

All areas were safe, clean, well equipped, well furnished and fit for purpose. Staff assessed and managed risks to people and themselves well. Staff understood how to protect people from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

Staff reported serious incidents clearly and in line with policy. Staff knew what incidents to report and how to report them. Staff recorded incidents on an electronic incident reporting system. Staff understood the duty of candour. They were open and transparent and gave people a full explanation if and when things went wrong. Leaders investigated incidents where appropriate.

The service had up to date incident reporting processes for internal incidents. We reviewed evidence that demonstrated the service understood its responsibility to submit statutory notifications. Governance processes showed leaders had oversight of incidents and took action to manage risks.

Leaders investigated incidents thoroughly. They reviewed incidents and identified any themes or trends. Any concerns could be further escalated to provider level if further support or guidance was required.

Staff met to discuss learning from incidents which was shared in a variety of ways. Managers discussed learning with staff in team meetings and staff provided examples of changes made to service procedures as a result of learning from incidents.

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 people was received to determine if people’s needs could safely be met. The service had multiple referral routes, including self presenting in person and online referral. Staff carried out assessments at the earliest opportunity to ensure people could receive treatment. If staff were unable to complete a full assessment, they completed an initial triage and booked the person in for an appointment.

The service had clear treatment pathways. There was a clinical team and a criminal justice team with separate pathways depending on the person’s needs. People were allocated keyworkers who continued to assess their needs as required.

The service had a process in place for service users who did not attend appointments to try to re-engage them with the service. The protocol included attempting to contact the person or their family or friends. Staff also contacted outside agencies such as the service user’s GP or they could request a welfare check. If staff were able to contact them, they arranged to re-engage them with the service, signpost them to alternative support or discharge them. The service held regular meetings to review cases and ensure the appropriate action was taken.

Staff engaged with people about their discharge planning. This was done in a way that the individual was comfortable with. There were lots of support options available to people who were nearing discharge. Staff worked collaboratively with partner agencies in the community to ensure people had a support network once they were ready for discharge. Staff supported people to access courses at a local college.

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 received training on how to recognise and report abuse, appropriate for their role. Staff compliance with safeguarding adults and safeguarding children training was 100% for both modules. Staff could contact the 2 safeguarding leads at the service if they required support.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff gave us examples where they had raised safeguarding concerns relating to issues such as domestic violence.

Staff knew how to recognise adults and children at risk of or suffering harm and worked with other agencies to protect them. The service had developed good working relationships with multiple external agencies to support safeguarding processes. Staff attended safeguarding meetings with relevant local agencies.

The service held a daily morning meeting which included a section to discuss any safeguarding cases they had. The service had safeguarding specialist leads, including domestic abuse champions who supported other staff members.

There were clear procedures in place to promote people’s safety. The safeguarding adults and children's policies provided guidance to staff on their roles and responsibilities in safeguarding. Staff we spoke to were clear on how to raise a safeguarding concern.

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 provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff completed risk assessments for each patient using a recognised tool. We reviewed 4 risk assessments. All risk assessments we reviewed included a full assessment of drug use, injection history or alcohol consumption where applicable, assessment of previous access to treatment, evidence of blood borne virus (BBV) assessments and evidence that harm reduction advice was provided.

The service was proactive in educating people about harm reduction and staff worked with service users to provide advice and tools to reduce harm. Staff provided people with naloxone. Naloxone is a medicine that is used to reverse or reduce the effects of opioid use. Staff encouraged people to carry naloxone to increase their safety in the community

Staff worked with people to develop and use risk management plans according to their needs. Records showed involvement with other agencies where appropriate. Staff demonstrated an understanding of the management of risk and were aware of the procedures to follow in the event of an emergency or if they needed further support. Staff followed clear personal safety protocols, including for lone working.

However, unexpected treatment exit plans were not specific to the individual but were part of the general disengagement procedure. It would be best practice to develop plans that were specific to people’s individual needs and circumstances.

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.

Staff completed and regularly updated thorough risk assessments of all areas and removed or reduced any risks they identified. Staff conducted regular health and safety audits. The service’s health and safety audit compliance from June 2025 to October 2025 was 100% for all areas. Fire risk assessments were updated for both sites on an annual basis, with other fire safety checks completed more regularly through the audit process. Fire alarms were tested on a weekly basis and a fire warden was identified at the beginning of each day. Legionella risk assessments were completed by an external company for both locations.

All rooms accessed by service users were fitted with alarms and staff were available to respond if required. Staff were allocated as first responders each day to respond to any alarms. The alarms were tested at both sites on a regular basis and there was a process to escalate any faults. All clinic rooms had the necessary equipment for people to have physical examinations.

Group rooms were brightly decorated with positive and motivational murals and the location was well furnished. The environment supported people who had mobility needs. Assessments or sessions could be held on the ground floor and there were disabled toilet facilities available on the ground floor. The service also had a lift.

However, the décor and furnishings were tired in places and there were lots of items being stored in boxes in the needle exchange room, which did not follow best practice.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have always enough qualified, skilled and experienced staff to provide safe care that met people’s individual needs.

The service did not always have enough staff to keep people safe. There were a total of 12 vacancies at the time of the inspection. The vacancies were for a range of different roles and the service was actively recruiting, but had been unable to fill some roles. At the time of inspection, 5 of the 12 vacant posts had been recruited to and staff were being onboarded or there was an interim staff member in place. A further 2 posts had agency cover in place. Staffing levels were improving, as the service previously had 23 vacancies. Funding for staffing was impacted by the service’s contract, which was due to be reviewed 2 weeks after the date of our on-site assessment.

Short staffing had impacted some areas of the service. Leaders discussed the possibility of having to close the service at Bretton for a day in September 2025 due to insufficient staff. One mortality review in April 2025 highlighted the impact of staffing on care which included missed follow-ups. We saw reference to complex cases being assigned to temporary staff which impacted on consistency in care.

Turnover of staff was 13.9% from April 2025 to October 2025. Staff sickness was 6.17% from April 2025 to October 2025 and 6 agency workers were used during the same time period.

Leaders did not always support staff to develop through yearly, constructive appraisals of their work. 51.7% of staff were up to date with their appraisal at the time of the inspection.

Staff were able to facilitate a programme of groups. Most people who used the service reported that their groups or appointments took place as planned, however some people we spoke to told us that groups were occasionally cancelled due to staff availability.

Caseloads were higher than the service had planned, but they were at an appropriate level in comparison to other similar services. This demonstrated that leaders put appropriate mitigations in place to ensure the continuation of service delivery.

Staff received and were up to date with appropriate mandatory training. The overall compliance rate for all mandatory training completion was 93.4%. The training was appropriate for the service user group. The lowest compliance was for basic life support training, which was 67%. This was due to low numbers of staff required to complete this training. Only 2 staff members had not completed it and one of those was a new starter. Clinical staff undertook additional training specific to working with people with substance misuse issues, including needle exchange training.

Staff received regular supervision. Supervision was due to be provided on a quarterly basis but was often completed more frequently. Staff were given a full induction to the service to ensure they were prepared for the role. Staff completed an induction checklist to ensure they were competent to carry out their duties.

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.

The service used an external company to carry out cleaning at the service. Clinical staff had a daily cleaning schedule for completion within the clinical areas. Staff completed regular cleaning audits across the service, which demonstrated good compliance.

Staff followed infection control principles, including handwashing, and referred to the infection control policy for guidance if required. All clinical areas were clean, had good furnishings and were well-maintained.

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.

There were systems and processes in place to safely manage medicines. Medicines were stored securely in temperature controlled areas which were monitored. Staff knew how to escalate concerns when a temperature reading went out of range. Staff could access emergency medicines easily. Staff were trained on how to use naloxone and people who used the service were encouraged to have a supply if needed.

Controlled drugs (CD), medicines with additional storage and recording requirements, were stored and recorded appropriately.

Service users were asked for their consent before their own GPs were contacted. Staff checked service user’s medical and drug histories prior to prescribing or issuing medicines. People were offered a urine drug screen at the start of treatment and regularly during their time with the service. People were offered blood borne virus tests prior to treatment (hepatitis B, hepatitis C, and HIV).