CGL Waltham Forest Adults Substance Misuse Service

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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.

The service maintained a strong safety culture, and staff reported, reviewed and learned from incidents through established governance processes. Leaders monitored incidents through live systems and discussed themes and actions in governance meetings, which supported learning and changes to practice. Staff described feeling confident to raise concerns and used structured processes to manage and escalate risk.

Staff embedded safeguarding processes from referral through to ongoing care. They screened referrals for safeguarding risks, responded promptly and worked with external partners such as the Multi‑Agency Safeguarding Hub (MASH) and Multi‑Agency Risk Assessment Conference (MARAC). Safeguarding activity was routinely monitored through trackers, audits and governance systems, and leaders had introduced safeguarding surgeries to strengthen oversight. Staff delivered harm reduction interventions, including naloxone provision and blood-borne virus screening, and involved people in managing risks.

Staff supported coordinated pathways, including referral, follow-up and engagement processes that reduced the risk of people being lost to services. Medicines management, infection prevention and control and environmental safety arrangements were in place and supported safe care. Staffing levels were sufficient, and staff reported manageable caseloads and access to support when managing risk.

However, recording of safeguarding and clinical information was not consistent across all records, which limited full assurance that risk was always documented comprehensively. Some people described inconsistent experiences at the Marsham Court venue, including difficulty accessing the building or limited staff presence, which reduced confidence in the reliability of the environment and could affect engagement with support.

We have not awarded this service a score for Safe.

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

Staff described a positive and open learning culture where safety discussions were routine and integral to day-to-day practice. They said they felt confident in identifying and recording incidents, and this was consistent with what we found in the incident records reviewed. Leaders maintained oversight through live incident monitoring systems, which showed 20 open incidents at the time of inspection, alongside 19 in review and one case awaiting completion of a training session before closure. Records showed this outstanding incident related to verbal abuse in November 2025, where staff had successfully de-escalated the situation without police involvement. Learning was recorded and additional training arranged for those involved. Monthly incident bulletins summarised recent events, identified themes and shared learning across the team, including good practice examples and feedback from staff.

Leaders described how incident learning was embedded into existing governance structures. Incidents were reviewed through the Integrated Governance Team Meeting (IGTM), where emerging themes, trends and risks were discussed. Staff told us they also discussed incidents in debriefs, team meetings and received incident bulletins, which reinforced shared learning. They gave examples of changes implemented because of incidents, including reinforcing prescription checking processes after an unsigned prescription and introducing an escalation pathway to address delays in communication with social care and referrers. These changes were reflected in meeting minutes and in staff accounts, showing learning was effectively embedded in practice.

Staff said they felt safe while working on site and described using personal alarms and monitoring CCTV during one-to-one appointments. Observations confirmed staff felt comfortable asking colleagues for support when managing risk. Staff also described learning from a high-risk incident, which resulted in changes to where a person was seen to improve safety. The decision-making process and learning from this event were documented within incident records.

A quarterly incident trend review for Q1 2025 identified themes such as aggression and near misses, racist abuse and triggers linked to deteriorating mental health. Leaders said staff experiencing challenging incidents were supported through the employee assistance programme and a duty manager protocol. They also had access to a regional safety lead when further advice was required.

The provider monitored compliments and complaints, which formed part of the overall learning approach. At the time of inspection, there were 9 live compliments and 1 live complaint. Documentation showed the complaint had been reviewed and staff responded appropriately, including addressing situations where consent to share information with a parent was not in place. Quarterly feedback reports indicated a pattern of significantly more compliments than complaints, and leaders reported an increase in complaints over the last 3 years due to improved accessibility rather than decreased quality.

People generally experienced coordinated pathways through the service, and many described positive experiences of communication between the service and partner organisations. One person told us liaison with their probation officer worked well, reducing the need to repeat information. Staff and leaders described strengthened referral screening processes that ensured essential information was gathered at the outset. Referrals were primarily received through an online form but the service also accepted walk‑ins, and staff supported people who needed help completing the referral. All referrals were screened for eligibility and safeguarding concerns, and staff made 2 telephone calls, sent a letter and contacted referrers where required to ensure people were not lost to follow‑up.

Staff told us that once all assessment sections were completed, the assessment was allocated to the relevant team within 24 hours, and workers were expected to contact the person within 5 days.

Leaders told us the average waiting time for assessment was 7 days, with assessments completed by phone. Where the Severity of Alcohol Dependence Questionnaire (SADQ) score exceeded 16, staff booked a nurse appointment with a target for completion within 10 working days. Leaders monitored performance through monthly reports that compared activity across services and supported local improvement. Records showed the service used an online “holding area” to manage demand and ensure staff had oversight of new referrals. At the time of inspection, 8 people were waiting in this holding area, including 1 who was outside the geographical boundary for treatment and was planned to be declined.

Staff described clear processes for assessing whether they could safely meet people’s needs. Where risks were identified at screening, staff collaborated with external health and social care partners to maintain safety and ensure continuity, including where people were supported by maternity services, mental health teams or social care. Records showed this approach contributed to joined‑up planning when people moved between services or transitioned out of treatment.

Staff also described how the contact‑preferences section of the electronic record was used to document consent for contact. Data‑consent forms and disengagement plans were uploaded in this section, and staff said consent was required to be updated annually. A member of staff carried out a weekly consent audit. The most recent audit showed that out of 675 people open to the service, 580 were compliant, with the remainder either approaching renewal or requiring an update. The staff member added the date of any upcoming appointment to support workers to complete the update during planned contact. Staff said this audit process had been in place for 3 to 4 months and that the number of overdue consent updates had significantly reduced.

People told us they felt well treated and trusted staff, which supported a culture where they felt comfortable raising concerns about safety. Observations showed people appeared well cared for throughout the inspection, and staff demonstrated awareness of risks during discussions. Leaders described a robust safeguarding process beginning at referral, where staff screened for urgent risks such as suicidal ideation, domestic abuse, children potentially at risk, recent hospital discharge and release from prison. High‑risk cases were allocated same‑day assessments to ensure safety concerns were addressed immediately.

Staff told us that they were completing designated safeguarding lead training. They said safeguarding was everyone’s responsibility and that staff should not wait to speak to a manager before escalating concerns. When a safeguarding issue was identified, an alert was recorded on the electronic care and treatment record and a safeguarding review added. Staff said reviews were completed fortnightly or monthly, using a weekly list provided by administrative staff showing cases due for review. Staff also described using a safeguarding tracker at the point of referral, which managers reviewed when referrals came from services such as social care, enabling early communication, sharing of minutes and ensuring keyworkers were invited to relevant meetings.

Daily flash meetings provided a forum for staff to discuss concerns and agree whether to escalate these to external partners such as the Multi‑Agency Safeguarding Hub (MASH), Domestic Abuse Perpetrator Panel, daily risk management meetings or the Multi‑Agency Risk Assessment Conference (MARAC). More complex safeguarding cases were escalated to weekly safeguarding forums or discussed with regional safeguarding leads. Managers were trained to Safeguarding Level 3 or above, and safeguarding responsibilities were documented within leadership meeting minutes, indicating clear lines of accountability.

Leaders described recent changes to how safeguarding learning and oversight were managed. They said the previous safeguarding meeting had been discontinued, and monthly safeguarding surgeries were being introduced. Each team leader would review between 3 and 7safeguarding cases during these surgeries, going through each case live on the system. Safeguarding adults’ surgeries were held monthly. All service users were flagged with a safeguarding tab so actions could be agreed during surgery discussions.

A safeguarding log contained 143 open cases at the time of inspection, 118 of which had been reviewed within the past six weeks. The log provided a detailed breakdown of case type, including opiate‑related and non‑opiate‑related categories, and staff explained that some cases without recent reviews related to people who had returned to treatment after periods of disengagement. The log was updated weekly and made available to managers and team leaders, who used safeguarding surgeries to review open cases and ensure notes were updated within expected timeframes. Case records contained detailed information about children, partners, social workers and family circumstances where relevant.

The provider’s risk register identified safeguarding as an area requiring improved oversight, particularly relating to record‑keeping quality. Leaders described improvements in 2025, with safeguarding activity rated as “improving” in November and “stable” by December. The register showed 97% of safeguarding cases had been reviewed within 12 weeks, and remaining work focused on improving note quality to ensure all risks were fully documented. All staff had completed mandatory training in safeguarding adults and children, the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards, which supported safe decision‑making.

Staff worked with people to understand and manage risks associated with substance use. People told us they received clear advice about substance‑related harm, and 1 person said they kept naloxone at home, which aligned with staff guidance. Leaders described how staff used structured harm‑minimisation approaches, including needle exchange, blood‑borne virus screening, and standardised tools such as the Alcohol Use Disorders Identification Test (AUDIT) and the Severity of Alcohol Dependence Questionnaire (SADQ). Staff demonstrated awareness of wider contextual risks, including domestic abuse, violence against women and girls, and cuckooing, and described using professional curiosity to explore potential safeguarding issues.

Staff described arrangements for rapid prescribing days, which ran between 10am and 3pm. They said a duty team leader, an entry‑into‑services worker, an opiate worker and a prescriber were on site. Staff completed tests, carried out assessments jointly with the prescriber and completed checks with the pharmacy. Staff also said that where someone had been off script for fewer than 14 days, a recovery worker could restart prescribing with prescriber approval; where more than 14 days had passed, the person would be seen directly by the prescriber.

Care records and observations showed staff delivered regular harm‑reduction interventions, including issuing naloxone, supplying test strips to someone concerned about potent synthetic opioids circulating locally, and completing safety actions with external partners where people presented with increased risk. For example, staff supported a person discharged unexpectedly from a mental health ward by agreeing immediate safety actions with the person and their hostel, and escalated cases involving domestic abuse to the Multi‑Agency Risk Assessment Conference (MARAC). Another case involved supporting a person using ketamine who stored excess quantities at home, where a child lived. Staff helped them reduce the quantity purchased, store medication securely and escalated concerns through a safeguarding referral. Five care records reviewed, including for a perinatal client, showed regular reviews of risk across physical health, mental health, and social domains, and reflected involvement of people in decision‑making.

The main registered location at Beulah Road provided a safe, clean and well-maintained environment that supported the delivery of safe care. We also considered people’s experiences at the Marsham Court venue, which is used by the service for group support. At Beulah Road, we observed secure entry systems, closed circuit television (CCTV) coverage and controlled access to staff only areas. Duty staff covered reception, so people were greeted, signed in and supported. Leaders told us there were always two staff members covering reception alongside a duty manager. Staff had completed first responder training, and leaders said the duty manager carried out walk arounds during busy periods to maintain visibility and support; duty responsibilities rotated daily. Personal alarms were available, and staff told us they felt safe working on site due to these measures. Fire wardens and first responders were allocated daily. Environmental records were up to date, including a June 2025 fire risk assessment, weekly fire alarm tests and a monthly premises audit, with learning from an October 2025 fire drill shared with staff.

Rooms at Beulah Road were soundproof, wheelchair accessible and had sufficient space for group and individual activities. Rooms at the Marsham Court venue also provided space for group activities.

Staff completed Personal Emergency Evacuation Plans (PEEPs) for people with identified needs, and planned weekly fire alarm tests were communicated in advance to minimise disruption during groups.

Four people attending groups at the Marsham Court site told us of occasions when there was no staff presence at reception and they were unable to access the building. When people arrive and cannot access the building or see a staff presence, it can create uncertainty about whether support will be available and reduce their confidence in the reliability of the service. For some, this may contribute to missed appointments or reluctance to return. Leaders recorded actions to review feedback and since the inspection, the provider told us that actions had since been taken to improve consistency of access at this venue.

The service had appropriate staffing levels, and staff told us caseloads were manageable. Leaders allocated work based on individual strengths, and staff described situations where caseloads were reduced to accommodate additional duties, such as work in police custody suites. Staff said they felt safe supporting people with higher levels of risk due to established safety plans, including paired working. Staff also described positive induction experiences tailored to their experience, and agency staff received a two‑week induction with competency checks for tasks they felt confident undertaking. Leaders said all necessary checks were carried out for agency workers, and supervisors provided them with support even when not contractually required.

Staff told us that training was good and that they could refer complex cases to senior staff. They said senior workers held smaller caseloads to allow capacity for multi‑agency work, including facilitating home visits and attending professionals’ meetings. Leaders told us that staff in the alcohol and non‑opiate team typically held average caseloads of around 50 people, which staff described as manageable.

Staff said supervision occurred monthly, exceeding the organisational requirement of 4 supervisions per year. Records showed 95% compliance with supervision targets. Leadership meeting minutes from late 2025 documented previous challenges in recording supervision and appraisal data following changes to reporting systems, but the January 2026 tracker showed all appraisals had been completed. Group rotas demonstrated appropriate staffing levels for group sessions, with at least 2 staff assigned to each group. Staff had completed a comprehensive programme of mandatory training, including basic life support and anaphylaxis, safeguarding adults and children, data protection and information security, display screen equipment, equality and diversity, health and safety, and learning disabilities and autism training, with the provider’s training records showing 99% compliance across all mandatory courses.

Leaders told us there were 2 vacancies at the time of inspection - 1 criminal justice worker post and 1 opiate team worker post. Both vacancies were being covered by agency staff, who had been in post for approximately 3 months, providing continuity for people using the service and maintaining team capacity. Leaders did not report any immediate risks arising from these arrangements, and staff said the use of experienced agency workers helped ensure caseloads remained manageable. Recruitment to these posts was being overseen by the registered manager, although timeframes for permanent appointments were not confirmed at the time of inspection.

The service maintained clean environments that supported safe care. We observed appropriate handwashing facilities, accessible hot water and hand sanitiser throughout both sites. Staff carried out routine checks to prevent the spread of infection, including monthly Legionella monitoring viewed on the digital dashboard. Clinical waste and sharps were disposed of securely, and daily cleaning was completed by an external contractor in line with the schedule. Staff had completed relevant training and described good infection control practice. An infection prevention and control audit was underway from 1 January to 28 February 2026.

The service ensured medicines and prescribing systems were safe and met people’s needs. People told us they had not experienced problems with their prescriptions. Staff described well established systems for prescribing, storage and medicines reconciliation. Medicines were stored securely, and controlled stationery was tracked to prevent misuse. Prescriptions were printed by clinical administrators following requests from prescribers and were handed directly to people or posted to pharmacies using recorded delivery. Void prescriptions were managed appropriately. All prescriptions were logged, supporting oversight of potential losses or theft. Clinical rooms were clean and equipped with handwashing facilities, emergency medicines and disposal facilities. A waste management company collected sharps bins and clinical waste.

Staff obtained full medicine histories and checked consent to share information with GPs. Where people did not have a GP, staff supported them to register. Staff wrote to GPs to request they not prescribe medicines that could conflict with treatment from the service. Medicines alerts were recorded electronically and cascaded through monthly bulletins. The provider’s medicines optimisation team shared learning and updates regularly. Pharmacy staff completed audits, and medical staff undertook Medicines Assisted Treatment (MAT) audits. Staff said they received substantial training on prescribing and described support from the lead nurse in reviewing training needs.

People were offered lockable safes to store medicines at home safely. Staff routinely offered naloxone and provided training on its use, supplying repeat doses as needed. They completed regular medicines reviews and discussed progress in MDT meetings. Staff followed NICE guidance and conducted ECGs, blood borne virus testing and urine drug screens where required. At the time of inspection, some Patient Group Directions (PGDs), which allowed staff to supply medicines such as hepatitis B vaccination without a patient‑specific prescription, had expired and were under review. The service used Patient Specific Directions (PSDs) to continue providing vaccination safely. The increased reliance on PSDs required additional administrative steps, although people continued to receive required medicines during this period. The Medication Assisted Treatment (MAT) flow chart described the step‑by‑step pathway from assessment through initiation, stabilisation, and ongoing review of treatment. Staff told us it helped them understand required checks, prescribing processes, and review points, supporting consistent and safe practice.

A 2025 service user report highlighted mixed views about prescribing processes. While many praised support from prescribers, others expressed concerns about delays, communication between pharmacies and the service, and wanting reduced supervised consumption where stable. In response, the provider strengthened communication with pharmacies, reviewed internal processes and issued clearer guidance on supervised consumption.