CGL Peterborough Aspire

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected and analysed data about outcomes and performance. They used this to identify improvements.

This service scored 82 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff were aware of the vision and values of the service. Staff attended a monthly integrated governance team meeting in which staff were able to contribute to discussions about the strategy for the service. We reviewed minutes of these meetings and saw that policy changes were shared and discussed with staff during these meetings. There was an agenda item for ‘Team Cohesion/Team Culture – Values, Transparency, Fairness’, where relevant information was shared and discussed.

Staff told us they felt there was a positive culture within the service and among their colleagues. Staff told us they felt supported and felt that the challenges of their roles were recognised by their immediate leaders. Staff felt diversity and inclusion was prioritised within the organisation.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively.

Leaders had the skills, knowledge and experience to perform their roles. All the pathways within the service had team leaders. They were supported by the deputy services manager and services manager, who reported to the regional director.

Leaders had a good understanding of the services they managed. They were aware of service performance and aware of challenges faced by the service. They collaborated with one another and other staff to develop solutions or mitigations and were supported by management at provider level.

Staff felt supported by managers and told us that they were approachable and engaged well with them. Staff told us leaders supported them with their development. However, some staff told us senior leaders were not visible within the service.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had a freedom to speak up process and most staff told us they felt they could confidently raise concerns with leaders and they would be dealt with effectively. The service also had a whistleblowing policy.

The service had a staff forum which allowed staff representatives to share feedback with leaders of the service. Leaders told us staff suggested they would value a faith room they could access. Leaders were exploring how they might be able to facilitate this. Most staff we spoke with told us there was a culture of openness in the team. Staff told us they felt listened to, and learning was shared among staff.

People had the opportunity to provide feedback about the service. They knew how to raise concerns and received a response. People also shared feedback about the service through their key workers. The service received positive feedback from system partners and carers. All feedback was collected and monitored by the service.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The overall provider had multiple equality, diversity and inclusion groups that all staff were welcome to access. Some of the groups run by the provider included an LGBTQ+ forum, accessibility forum, menopause group and a race equality forum.

The service employed a diverse team of staff from international backgrounds. Employment practices promoted equality of opportunity. Most staff members told us they felt they were treated fairly. Some staff told us they felt their caseloads were unbalanced among their team.

Staff were able to apply to work flexibly. Lots of staff had flexible working arrangements in place. Leaders tried to facilitate requests where possible. This was balanced with ensuring the continuation of service delivery.

Managers put reasonable adjustments in place for staff members to help them carry out their role. For example, reasonable adjustments were made for staff members who had a health condition to support their health at work. Reasonable adjustments were documented appropriately.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Meetings at team and management level followed a clear structure to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Integrated governance team meetings (IGTM) discussed multiple topics including lessons learnt, policy updates and good practice. Information discussed in leadership meetings was shared with all staff in IGTMs. Cases were discussed in the individual team meetings held by each pathway with actions documented.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. Staff participated in mortality meetings, which reviewed cases where there had been deaths. The meetings were focussed around learning, identified actions and changes in practice where appropriate.

Leaders maintained and had access to a risk register which included appropriate risks and actions in place to mitigate them. The risks were allocated to an individual and reviewed regularly. Progress was monitored on a regular basis. The risks identified were graded by their severity.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. For example, clinical staff completed regular audits of medicines and prescription management. The audit results provided assurance around the safety of medicines and prescription processes.

Leaders had access to information to support them with their management role. This included information on the performance of the service, staffing and service user care. Leaders collected and reviewed data to monitor the performance of the service. The service had key performance indicators (KPI) set by their commissioners to help monitor and improve progress in performance. The service had quarterly reviews with their commissioners where performance and trends were discussed.

Leaders had access to information which ensured they had oversight of risk and performance. They were able to track information such as whether people were due for a medical review or whether people had received contact in the last 4 weeks. Leaders shared key metrics with all staff members on a weekly basis.

The service had plans for emergencies – for example, loss of IT access or an outbreak of illness. The service had a business continuity plan in place for both locations.

We scored the service as 4. The evidence showed an exceptional standard. The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

Staff and leaders collaborated effectively with a wide range of external stakeholders, such as commissioners, service delivery partners, statutory agencies, voluntary and community organisations. Staff and leaders continued to build positive working relationships to benefit people who used the service.

Leaders and staff undertook extensive work with local partners to promote equality, diversity and inclusion throughout the service. The service worked with local partners to develop a ‘community connector’ role at the service to work with harder to reach communities and supported them to access treatment services. The staff who worked in this area built new connections with partner organisations. For example, staff from the service attended two blood borne virus (BBV) testing evenings alongside other partner organisations to increase the presence of drug and alcohol services in the community and to normalise conversations around substance misuse. Outcomes from this outreach work included numerous referrals into the service via a local GP surgery whose patients were predominantly from ethnic minority backgrounds. There was an increase in women from harder to reach communities accessing treatment. Through this initiative, staff also participated in wider work of addressing stigma and trust in community services. The project had 8 successful treatment completions.

The service worked closely with vulnerable women who were at risk of sexual exploitation. This involved joined up working with local police and GP surgeries. The service had a vulnerable women’s outreach worker who visited women and delivered interventions. Staff encouraged women to report abuse to the police and encouraged them to attend GP surgeries for cervical screening. Women only groups were available within the service for them to attend.

The service worked with other similar organisations to share best practice. Feedback received from stakeholders was positive and highlighted the impact the service has had on engagement in treatment. Other feedback received from partner agencies highlighted the passion staff had for supporting service users, advocating for them and ensuring they had the support they needed.

The provider organised a recovery walk in September 2025 for service users to attend. Service users were able to network with other people who were also in recovery and shared their own lived experiences with others.

We scored the service as 4. The evidence showed an exceptional standard. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice.

Leaders continually sought to make improvements to the service to benefit people and improve their safety. For example, staff identified vulnerable people who were at risk of cuckooing. Cuckooing is a practice whereby criminals take control over the home of another person to use it for criminal activity. This often includes drug dealing or production. Staff collaborated with local agencies which resulted in the creation of a coordinated task and finish group involving key stakeholders including the police, safeguarding and housing teams. The service employed a full time ‘cuckooing’ recovery coordinator. The outcome of this initiative was there were no negative housing outcomes (where someone has been homeless, rough sleeping or lost their property as a result of the work that took place). Prior to this the service identified negative housing outcomes in around 80% of cases.

Staff identified that a high proportion of service users were smokers. Many service users had complex needs and found it difficult to access and engage in smoking support. Staff set up an accessible smoking support service adapted to the needs of service users. Staff created a service with 2 different pathways to suit individuals and provided education about safety and harm reduction by using vapes. From June 2025 to September 2025 the service had received 95 referrals and supported 37 service users onto a pathway to reduce or stop smoking.

Staff participated in a national pilot project delivered by the provider and another partner agency to support women who were homeless, at risk of homelessness or in unsafe or unsuitable accommodation. The service provided drug and alcohol treatment support in the form of; assessment, psychosocial interventions, harm reduction and safer use advice. They also provided housing support and access to a mental health link worker due to the recognition that people often presented with co-occurring conditions.

The service had a transporter van which was used for various outreach activities, including to provide holistic and rapid support to homeless people in the local area. Staff provided assessment into treatment, harm reduction advice, naloxone, blood borne virus (BBV) interventions and support for people to make a homeless presentation to access housing support. A non-medical prescriber attended weekly to provide rapid prescribing. This initiative had improved continuity of care for released prisoners who were homeless, improved access to safe prescribing, reduced harm and increased engagement from the criminal justice cohort. There was also reduced interaction with enforcement officers and anti-social behaviour teams.