CGL Norfolk Alcohol and Drug Behavioural Change Service

On this page

• 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

We rated safe as good. We assessed 8 quality statements. Staff responded promptly to deterioration in peoples mental and physical health. The service used systems and processes to safely prescribe, administer, record and store medicines.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

Staff we spoke with knew how to record incidents or accidents and told us they felt safe to do so. Staff told us accidents and incidents were suitably investigated, and they received an effective debrief following incidents. Staff understood duty of candour and were open and transparent if and when things went wrong.

Leaders were able to explain the systems and processes in place for learning from accidents, incidents and complaints and could demonstrate how learning had been shared from incidents. For example, staff were reminded to carry out daily naloxone audits during the morning flash meetings.

The service completed regular mortality reviews, where any individual deaths were discussed with keyworkers and any learning shared between staff. In addition to this, the provider held monthly Integrated governance team meetings (IGTMs) regular team meetings and daily flash meetings. Learning was shared across CGL services locally and across CGL as an organisation.

The service worked with people and their partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. The service ensured continuity of care, including when people moved between different services.

There were a variety of ways in which people could be referred into the service, including self-referral through a secure online referral system, referral by other agencies or telephone referrals. People could attend a walk-in appointment at various times throughout the week and receive an initial assessment on the same day. The service did not have waiting lists, those referred were offered a time and date to be assessed in a timely manner. Staff saw urgent referrals quickly and had a team whose role was to carry out initial assessments.

The service had a re engagement policy and procedure in place, which included maximising engagement with people and a procedure for re engaging people at different stages in treatment.

The service worked with people to understand what being safe meant to them as well as with partners on the best way to achieve this. The service concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and they made sure they shared concerns quickly and appropriately.

Staff had received safeguarding training and were confident in using that training. Overall compliance with both safeguarding adults and safeguarding children training was 100%. Staff understood how to monitor for signs of abuse or escalate concerns. The service had good oversight of safeguarding concerns, action taken and lessons learnt.

Leaders could describe how safeguarding concerns were managed, and information shared at various team meetings where safeguarding was a standing agenda item. All team leaders had completed additional safeguarding training and acted as designated safeguarding leads, supporting and advising staff throughout the county.

Staff understood how to protect people’s human rights, including their rights under the Mental Capacity Act (MCA) and the Equality Act. Overall, 100% of staff had completed MCA and Deprivation of Liberty safeguards training.

The service had a clear process to record safeguarding concerns, and notifications were made to the local authority or CQC in a timely manner. The service ensured other authorities or agencies were involved if needed.

The service worked with people to understand and manage risks by thinking holistically so that care met their needs in a way that was safe and supportive and enabled them to do the things that mattered to them.

We reviewed 21 risk assessments during this inspection. Staff carried out risk assessments using a recognised tool with people as part of the initial assessment and updated these within the providers timescales or when risk changed. Staff discussed people’s risk or any changes in risk during the daily morning meeting.

People we spoke with felt risk was managed well within the service and felt involved in their risk assessments.

Risk assessments included providing people with medication lock boxes to store medication safely at home and naloxone, a medicine that rapidly reverses an opioid overdose.

Staff caseload sizes were dependent on complexity and teams regularly discussed caseload sizes in supervision and team meetings to ensure people’s risk was taken into account.

Staff understood risk management and were aware of the procedures to follow in the event of an emergency or if they needed further support to manage risks to people. Staff followed clear personal safety protocols, including for lone working.

The service detected and controlled potential risks in the care environment and made sure that the equipment, facilities and technology supported the delivery of safe care.

Staff carried out regular risk assessments of the environment. Fire drill rehearsals took place at each hub weekly. All services had a suitable alarm system in all rooms accessed by people; alarms were tested monthly as part of the hub risk assessment.

Clinic rooms were fully equipped for people to have thorough physical examinations and staff had access to emergency drugs that staff checked regularly. All staff carried naloxone on them (a medicine that rapidly reverses an opioid overdose) and were trained in how to administer it.

The hub at Norwich was accessible, spacious, and welcoming and people could make themselves hot drinks. The hub had access to several group rooms, clinic rooms and 1:1 rooms. The Thetford hub was small and had one 1:1 room and a single group room for people’s appointments. However, staff utilised the local community and home visits. The hub at Great Yarmouth had several group rooms, a clinic room and enough 1:1 rooms to meet people’s need. The service was accessed by stairs to get into the building. However, the service told us they could utilise a ramp if needed and that they could also see people in the community or as part of a home visit.

People described the services as clean, with good up to date information in the reception area. No one spoken with had any concerns around visiting the locations.

Managers made sure there were enough qualified, skilled and experienced people, who received effective support, supervision and development and worked together effectively to provide safe care that met people’s individual needs.

CGL Norfolk Alcohol and Drug Behavioural Change Service employed 131 staff members and reported a vacancy rate of 4% in July 2025. Between May 2025 and July 2025, the sickness absence was under 3%. Agency staff were used when required and the rate for agency staff was reducing as new staff were being recruited. In May 2025 there were 9 agency staff used, this had reduced to 4 agency staff being used throughout July 2025.

Staff had received and were up to date with appropriate mandatory training. The training was appropriate to support the needs of the people using the service.

The service assessed and managed the risk of infection, detected and controlled the risk of it spreading and shared any concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. All hubs were clean, had good furnishings and were well-maintained.

Staff adhered to infection control principles, including handwashing. The provider had policies in place in line with best practice guidance around infection prevention and control. The service had cleaning schedules and checklists in place that had been completed.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happened.

People who collected medicines from a pharmacy confirmed they were involved in choosing a convenient pharmacy to suit their needs and that collection regimes were discussed with them prior to commencing treatment. The service used a review of dispensing regime form to decide on prescription regimes; this was completed by keyworkers at regular risk reviews. People confirmed they had access to naloxone and locked boxes to store medicine if required.

Staff followed good practice in medicines management including transport, storage, dispensing, administration, medicines reconciliation, recording, disposal and did it in line with national guidance.

There were systems and processes in place to safely manage medicines. Medicines were stored securely in temperature-controlled rooms which staff monitored. Staff knew what action to take when temperature readings went out of range. Staff could access emergency medicines easily and always carried a supply of naloxone with them during their working day for use in emergencies. Staff were trained on how to use naloxone and people were encouraged to take home naloxone.

The needle exchange and clinic rooms at all hubs were clutter free, clean, and well equipped. Overall, 100% of staff had completed basic life support training.

Medicines and prescription forms were kept securely. Their use was monitored in line with national guidance. The service had systems to ensure staff knew about safety alerts and incidents, so people received their medicines safely. Medicines incidents were reported on an electronic system and fully investigated.

Norwich and Great Yarmouth hubs were carrying out community alcohol detoxification groups with people which were proving successful. People who met the criteria for community alcohol detoxification attended the hubs daily for a week where they received medication to support alcohol detoxification, attended motivational groups, and had their observations and physical symptoms noted. We reviewed 4 care records for those who had attended a community alcohol detoxification at the Great Yarmouth hub and noted that all those who had received a detox had been monitored and received motivational support during their detoxification.

Thetford and Kings Lynn hubs had found that community alcohol detoxes had not been taken up as successfully as the other 2 hubs.

People were offered a urine drug screen prior to treatment and at regular intervals thereafter with the service. People were offered Blood Borne Virus testing at the start of treatment and throughout their treatment episode. Hepatitis vaccinations were routinely offered at the point of assessment and at review appointments to all people.

At the time of inspection, the compliance for medical reviews was 94.43%.