CGL Waltham Forest Adults Substance Misuse Service

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

The service delivered effective care through timely and holistic assessments that considered substance use, physical and mental health, social circumstances and risk. Staff applied evidence-based guidance, including NICE standards and the Orange Book (2017), and used structured clinical tools such as AUDIT and SADQ to inform treatment.

People accessed treatment quickly, including through rapid prescribing clinics, and staff delivered pharmacological and psychosocial interventions tailored to individual needs. Staff monitored outcomes through structured processes, including Treatment Outcome Profiles (TOPs), and used regular reviews to adjust care in response to progress.

Staff worked collaboratively across multidisciplinary teams and external partners, including GPs, social care and maternity services, to support coordinated care. Staff routinely sought and recorded consent and completed mental capacity assessments where required, supported by governance oversight and training compliance.

However, some variability in documentation remained, including isolated gaps in clinical recording, which limited full assurance that records consistently reflected practice. Some people described inconsistency in coordination, including not always being informed when keyworkers changed or feeling less supported outside prescribing appointments, which could affect continuity and engagement.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

Staff ensured people received timely, holistic assessments that considered substance use, mental and physical health, safeguarding, social circumstances and communication needs. Leaders and staff described rapid prescribing clinics on Mondays, Tuesdays and Thursdays where people could walk in without an appointment, receive an assessment, complete dry blood spot testing and take-home naloxone on the same day. Staff said prescribers knew people well and initiated conversations about treatment options, including Buvidal (a long‑acting injection used to treat opioid dependence), during or following assessment where this aligned with need. Leaders told us the timetable for people using the service followed the provider’s ‘Change, Grow, Live’ model and included mutual aid groups for carers and people using the service, which supported continuity between assessment and intervention. Staff received role relevant training, including on chemsex and violence against women and girls, to inform assessment quality and risk recognition.

Staff updated the assessment format in 2022 to include a timeline feature and ensured administrative staff completed referral and triage information as fully as possible before booking the full assessment. Staff described the assessment as person centred, covering risk of harm to self or others, safeguarding, assessment outcomes and initial plans, National Drug Treatment Monitoring System (NDTMS) consent, agreed interventions and Treatment Outcome Profile (TOP) outcome measures. The assessment included questions about protected characteristics and communication needs. Staff identified that most referrals (around 80–90%) related to non opiate use, with problematic local substances including cannabis, cocaine, ketamine and novel psychoactive substances. These accounts aligned with the records we reviewed, which showed personalised plans, involvement of people in decisions and responsiveness to changes in need.

Records demonstrated that clinical tools were applied where indicated, including the Clinical Opiate Withdrawal Scale (COWS), non medical prescriber assessments and neurological assessment documentation. One record showed how care planning for a person receiving Buvidal linked to perinatal pathways with regular reviews in place; another captured the person’s views across substance use, physical and mental health and social needs. Mental capacity was considered during assessment, and staff completed appropriate capacity assessments where needed. Feedback gathered during inspection highlighted rapid access to treatment as a positive feature of the model.

Staff delivered care and treatment in line with established evidence-based guidance. Leaders and staff described applying national standards, including the Orange Book (2017) and National Institute for Health and Care Excellence (NICE) guidance, and this was reflected in the care records we reviewed. Leaders attended regional and registered manager forums where current best practice was shared and then cascaded to the team. Staff had access to structured psychosocial resources, including motivational interviewing (MI) supported by national oversight, and the ‘Foundations of Change’ training package that underpinned both alcohol and drug pathways.

People told us therapeutic approaches were used effectively. One person said their keyworker “understands how my brain works,” and another valued the provider initiated referral to their GP for a neurodiversity assessment. Records corroborated the use of MI, harm minimisation interventions and structured one to one psychosocial work. Documentation also showed clear oversight of the Buvidal pathway, including consistent physical observations at each attendance, and appropriate coordination with external professionals where indicated, for example arranging psychotherapy alongside the service’s psychosocial offer.

However, in 1 case the record did not include a documented mental health assessment despite concerns about compromised capacity. In another, a suspected dementia diagnosis was referenced without a clear capacity assessment recorded. Staff later explained that such assessments would typically be completed by a nurse or doctor and documented in medical notes, and further review confirmed the dementia concern was no longer current.

Staff worked effectively across internal teams and with external partners to support joined up care. They described strong links with domestic violence services and well established multi agency safeguarding arrangements, including regular contact with a Multi Agency Safeguarding Hub representative. Teams held 2 multidisciplinary team meetings each week, overseen by the consultant, and team leaders recorded actions and decisions. Staff reported effective relationships with probation, police, integrated offender management services, GP surgeries and local authority teams. Leaders told us they used daily risk management processes with partners across the borough, and urgent concerns were escalated swiftly through flash meetings and team huddles. Fortnightly managers’ meetings supported information flow on safeguarding, clinical activity and operational performance.

Care records reflected this partnership working, with evidence of liaison with maternity services, GPs, social care and MARAC, and of MDT involvement across several files. Keyworkers consulted medical staff where needed, which ensured clinical oversight of complex decisions. The provider’s risk register showed ongoing work to finalise information sharing agreements with partner agencies, overseen by a national data protection lead, and most agreements were already in place.

However, experiences of coordination were not consistently positive. Some people said they were not always informed when changes were made to their allocated keyworker and felt they were “passed from person to person.” One person described poor communication between their housing worker and the service, and another said they mainly attended for rapid prescribing and felt unsupported by keyworkers, describing one to one sessions as “non-existent”. Unclear communication about changes in keyworker allocation can create a sense of instability for people who rely on consistent relationships to engage with treatment. It may lead to people feeling uncertain about who is supporting them and can affect how able they feel to discuss emerging risks.

Staff supported people to improve their health and wellbeing through a range of interventions. Leaders and staff described naloxone provision and training, access to needle exchange, blood borne virus screening and nurse led health assessments. Where required, nurses followed up with hospital liaison pathways. Staff referred people to GPs for physical health issues and linked with specialist and community resources, such as the East London Out Project and local foodbanks, to address wider determinants of health. A monthly NHS run sexual health satellite clinic offered additional access to healthcare on site.

People described how structured groups and information helped them plan their time, reduce substance use and increase positive routines. One person said they were “thriving rather than surviving” after engaging with groups and another told us that “groups are the best thing” about the service.

The timetable included regular meditation and mindfulness sessions, and staff encouraged participation in activities that promoted wellbeing. Observations showed the environment supported healthier choices, with a dedicated needle exchange room, harm reduction information, and signposting to community schemes offering fresh fruit and vegetables as well as to local foodbanks and community health resources.

Care records showed systematic monitoring of physical health needs and timely action where concerns were identified. We saw examples of regular ECGs, liver function tests, blood borne virus reviews, and referrals for smoking cessation and sexual health services. Physical health needs captured in assessments aligned with the care plans in place, demonstrating coherent planning and follow through. However, 1 person said they were encouraged to attend smoking cessation support but could not access the location due to mobility issues and felt no alternative was offered.

Staff monitored progress and used outcomes data to inform ongoing care and drive improvement. Leaders described a fortnightly refreshed activity dataset covering Treatment Outcome Profiles, blood borne virus screening, naloxone provision and medical reviews. Staff told us they completed the Client Information Review and Sub Intervention Review on a three monthly cycle and reviewed TOPs on the same cycle to maintain oversight of psychosocial and pharmacological interventions. A weekly activity audit report went first to team leaders and then to the wider team; staff said these supported case management discussions and prompted action when contacts or interventions were overdue. A daily “last positive contact” report highlighted anyone not seen within 28 days so teams could make prompt contact.

Records reflected the application of these monitoring processes, with clear alignment between identified needs and care planning, including physical health monitoring and referrals. People also described outcome focused support, for example help to access counselling and complete forms, and 1 person said they were “glad” to have the service’s support. Staff said monitoring helped them recognise milestones when people achieved goals. Leaders described how training on neurodiversity informed practical adjustments to appointments and interventions where needed, which supported people to remain engaged and progress. The provider also participated in the FORWARDS 2 clinical trial, with 5 participants from the service, exploring whether baclofen could support community based methadone detoxification, which leaders said strengthened partnerships with NHS and academic collaborators and contributed to the evidence base.

At the previous inspection, CQC found staff were not consistently recording consent to treatment. Leaders told us this had been addressed. Staff now sought and recorded consent in line with legislation and guidance, capturing it during assessment and checking it regularly thereafter. Records we reviewed showed consent discussions present in people’s notes. Staff told us prescribers completed mental capacity assessments where required, and training records showed all staff had completed mandatory Mental Capacity Act and Deprivation of Liberty Safeguards training. The MCA policy, embedded within the safeguarding adults policy, aligned with national guidance.

The provider’s risk register showed consent remained under routine review to maintain compliance with current guidance. Leaders explained that processes had been updated to ensure regular checks of consent and capacity as appropriate. This had been risk rated as low and scheduled for review in February 2026.