My Recovery Tameside

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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

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

We saw evidence that people were protected from abuse and avoidable harm. Staff assessed and managed risks to people using the service and themselves well. Staff understood how to protect clients 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 incidents well, supporting people using the service and staff who were involved in incident and investigating incidents appropriately to identify any lessons which could be learned. The premises at both sites were safe, clean, well equipped, well-furnished and fit for purpose, although the decor at Ashton was in need of refurbishment.

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.

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.

No serious incidents occurred at either of the service’s 2 sites in the 12 months preceding our inspection. The provider had systems in place for monitoring other significant events, including safeguarding referrals and deaths of people using the service. Records we reviewed evidenced that incidents were reported in a timely manner and prompt action was taken in response.

All staff we spoke with knew what incidents to report and how to report them. The staff we spoke with could give examples of things they should report as incidents including; safeguarding issues, concerns raised by clients and concerns relating to the premises. Staff understood the duty of candour. They were open and transparent and gave people using the service a full explanation if, and when, things went wrong. Staff were debriefed and received support after a serious incident. The staff we spoke with who had been involved in incidents told us that they had felt well supported in relation to this.

Staff received feedback from investigation of incidents, both internal and external to the service. The registered manager told us that an incident bulletin was circulated to staff to provide a summary of learning from incidents within the service and within CGL more widely. The service also took part in a partnership panel, commissioned by the local authority and delivered by Liverpool John Moores University, which collected and reviewed data from multiple stakeholders about drug and alcohol related deaths, to enable learning and ongoing improvement of services. There were also local team meetings at the service and area meetings attended by the registered manager within CGL at which incidents and lessons learned were regularly discussed. We saw minutes of these meetings which confirmed this as well as example incident bulletins which had been circulated to staff.

The registered manager gave some examples of improvements which had been made as a result of learning from incidents. An increase in incidents of aggression in the reception area at Ashton had been identified and this prompted environmental improvements including new chairs and art displays, which resulted in a decrease in incidents because some previous sources of frustration for people using the service had been removed. Also, some changes had been made to the systems for sending information to clients’ GPs following some incidents where information had been sent to the incorrect practice, which again had resulted in improvement in this area.

There was an effective system in place to ensure all deaths of people using the service were reviewed at a learning from deaths panel. This ensured that, if there were any lessons to be learned in relation to the individual’s care, these would be identified and action taken in response. There had been 30 of these reviews in the 12 months preceding our inspection, which resulted in a range of improvement actions including additional staff training and changes to internal systems and processes. Team meeting minutes evidenced that learning from deaths was a regular agenda item. The service worked effectively with external partners in relation to any formal investigations of deaths of their clients, including Coroners’ inquests. The registered manager had recently completed some additional training in relation to Coronial law which had been funded by the provider to support her in this aspect of her role.

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 each client was received to determine if their needs could safely be met. This included a triage process to determine levels of risk and a full clinical assessment where more detailed information was gathered at the start of each individual’s treatment journey. The service also liaised with GPs and other stakeholders involved with people’s care to inform their assessment of needs.

All the records we reviewed included a detailed assessment of needs which informed a person-centred recovery plan. The registered manager and the staff we spoke with described how the service worked with stakeholders in the wider health, social care and criminal justice systems to ensure information was shared, to enable continuity of care for people throughout their pathway through the service, and in relation to their discharge.

We received positive feedback from a wide range of external stakeholders about how the provider worked with them. People using the service told us that the service was good at supporting them with other agencies they were involved with, such as housing and social care. The service monitored whether discharges were planned, unplanned and neutral and over the 12 months prior to our inspection the largest proportion of discharges from the service (47%) were planned, with 38% being unplanned and 15% neutral. The provider reviewed unplanned and neutral discharges to identify if there was any learning which could be used to improve the service.

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 were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. The provider had detailed policies relating to safeguarding adults and children which clearly set out the process for staff to follow to report concerns. Information about safeguarding was also displayed at both sites for staff and clients. The staff we spoke with confirmed they had received safeguarding training in relation to children and adults at risk. The provider’s training data evidenced that, at the time we inspected, 100% of staff were up to date with safeguarding children training and 98% of staff were up to date with safeguarding adults at risk training at a level appropriate to their role.

The service had effective systems in place for monitoring safeguarding concerns to ensure appropriate follow up action was taken. The provider’s records evidenced that 15 concerns were referred to the local authority safeguarding team in the 12 months before our inspection. These related to a range of issues including suspected financial abuse of someone using the service, disclosure by clients of historical physical or sexual abuse and concerns about self-neglect or vulnerability of clients. All these concerns were also notified to CQC as required.

The service worked in partnership with local safeguarding structures to ensure complex and high risk concerns were identified and actioned appropriately. We saw minutes of the Tameside Adult Safeguarding Partnership Board meetings which evidenced regular attendance at their complex and high risk panel meetings by representatives of the service, where the local health and social care, criminal justice and safeguarding services worked together where necessary to meet the needs of individuals due to complex vulnerabilities and/or public safety concerns. The service also had a regular safeguarding multi-disciplinary team meeting to ensure ongoing review internally of any safeguarding concerns and the action taken in response. We received positive feedback from local safeguarding stakeholders about how the service engaged with them.

Mental Capacity Act

Staff received training in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. At the time we inspected, 99% of staff were up to date with this mandatory training. The provider had a detailed policy on Mental Capacity Act compliance and staff were aware of this and said it was accessible. The registered manager said that the service's psychiatrist was also available to discuss any issues arising in relation to people’s capacity to consent. Staff we spoke with were able to describe potential situations where a client’s capacity might need to be assessed, for example when people presented to the service under the influence of substances.

Records evidenced that, for people who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately – all the records we reviewed included a documented capacity assessment. When people lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. Records evidenced that capacity was discussed in medical reviews and multi-disciplinary team meetings where relevant to the individual’s care.

The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to clients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 13 sets of records during the inspection, which all included an up to date risk assessment and risk management plan. The risk management plans included information for staff on how to manage unexpected exits from treatment and there was a clear process in place to ensure staff made every effort to re-engage people who unexpectedly disengaged with the service, including liaison with other stakeholders involved with that person where appropriate. The records we reviewed evidenced that risk assessments and care plans were completed with people’s involvement and that they were offered copies of these documents.

Staff communicated with clients so that they understood their care and treatment, including finding effective ways to communicate with clients with communication difficulties. The people we spoke with told us that staff communicated well with them and gave them all the information they needed about their treatment. The registered manager confirmed interpreters could be arranged as needed for people whose first language was not English and that written information could also be translated, although we were told it was rare for people who were not fluent in English to access the service.

Staff enabled people using the service to give feedback on the service they received. The registered manager told us that 3 monthly surveys were sent to clients to seek feedback on their experience to inform ongoing improvements. We saw evidence that action was taken in response to feedback including in areas where this related to potential areas of risk, such as prescription management and availability of staff out of hours.

The care environment at Ashton was tired and in need of refurbishment. However, the service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The décor at Ashton was tired and in need of refurbishment, for example due to damaged paintwork, but the décor was maintained to a good standard in Hyde. Staff at Ashton also told us that they felt the bright colour of the clinic room wall did not promote a relaxing environment for people using the service.

However, records confirmed that clinical and non-clinical areas were cleaned daily and cleaning equipment was stored safely and in line with infection prevention and control best practice. The provider’s records also included fire risk assessments for both sites, 6 monthly fire checks, annual gas safety inspections and service records for the lift at the Hyde location. These records were usually up to date, however the emergency lighting check at Hyde should have been completed in May 2026. Staff told us that maintenance issues were resolved promptly by CGL’s facilities team and there was an online system in place for these requests to be logged. Staff had access to alarms in all interview rooms and there was a system in place for these to be tested weekly. We observed this happening during our time on site. The clients we spoke with all told us that the premises were always clean and safe and no concerns were raised about the care environment. Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly, including naloxone (used for emergency reversal of an opiate overdose).

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

The service was well staffed at the time of our inspection, with only 1.49 whole time equivalent (WTE) recovery coordinator vacancies and no vacancies for any other roles. The provider was in the process of recruiting to both vacant roles, one of which had been provisionally filled, with pre-employment checks taking place at the time we inspected.

The service had an average sickness absence rate over the 12 months preceding the inspection of 6%, which was mostly due to short term sickness absence. The turnover rate for the service in the 12 months preceding the inspection was 17% (14 staff leaving over the course of the year). The provider collected and analysed sickness absence and turnover data for the service and no themes or trends of concern had been identified in relation to either data set.

Use of bank and agency staff was low with only 8 agency staff working at the service in the 12 months preceding the inspection, this was to cover vacancies and sickness absence.

We reviewed 3 staff files, selected at random, which all showed that staff had received appropriate pre-employment checks, including Disclosure and Barring Service checks, references and checks of their professional registration where relevant. All staff received a comprehensive 4 week induction when they started working at the service. Staff had received and were up to date with appropriate mandatory training, with over 90% of staff at the service being up to date with all mandatory training modules at the time we inspected. The training was appropriate for the services being provided and included modules on basic life support, information governance, health and safety, equality and diversity, the Mental Capacity Act, safeguarding adults and children, and on meeting the needs of people with a learning disability and autistic people.

Staff also told us they were supported with additional training and continuing professional development appropriate to their role and we saw example presentations delivered to staff about a wide range of topics relevant to the services provided, for example up to date guidance about specific illicit substances.

The people using the service we spoke with told us that the staff they worked with were knowledgeable and supportive and went “above and beyond” for them. Staff told us that they had the time to complete training and professional development and said they felt well supported by immediate managers and the provider organisation.

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.

Staff maintained equipment well and kept it clean. The clinic rooms at both sites were clean, tidy and well maintained, with no hygiene or health and safety issues. Handwashing sinks were available for staff and personal protective equipment (PPE) such as disposable gloves and aprons were available at both sites. All areas of both sites were clean and furnishings were clean and in a good state of repair, although the decor in Ashton was in need of refurbishment. Cleaning records were completed in relation to both sites and demonstrated daily cleaning on all the days the services was open. Clinical waste, including sharps, was stored safely and collected regularly and the needle exchanges at both sites were well managed, with safe storage arrangements for used needles.

The people using the service we spoke with who regularly attended both Ashton and Hyde said that the premises were always clean when they attended. The service audited compliance with infection prevention and control standards and took action on the results of these audits. The audits included checks of hand hygiene compliance, availability of PPE, safe distribution and disposal of sharps in the needle exchange and clinical environments, environmental cleanliness, waste management, equipment decontamination and staff knowledge. Actions taken in response to audit findings in the 12 months before our inspection included additional staff training, the provision of portable kits to staff working in the community including PPE and hand sanitiser and improvements in the systems for environmental cleaning and waste management. Implementation of these improvements was monitored through the service’s clinical meetings, where infection prevention and control was a standing agenda item.

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

Staff followed good practice in medicines management (transport, storage, dispensing, administration, medicines reconciliation, recording and disposal of medicines) and complied with national guidance. Medicines were stored safely at both sites, the only medicines stored on site were emergency medicines and, at Ashton, Buvidal long-acting buprenorphine, as this medication was administered on site by injection to a small cohort of clients. This was stored safely and in line with legal requirements for the secure storage of controlled drugs. There were systems in place for controlled drugs waste to be disposed of safely, to reduce the risk of diversion. We reviewed prescription records for 30 clients and did not identify any errors or concerns. Staff involved in managing medicines at the service were knowledgeable and competent and people using the service told us that they felt well supported in relation to their prescriptions.

Written information was available for people about all the medicines prescribed by the service and people confirmed they had access to this. The prescribers we spoke with told us they felt well supported with regular clinical supervision and reflective practice sessions. There were systems in place for monitoring the management of medicines within the service including ordering, storage, prescribing, administration and disposal. This included audits and checks by CGL’s pharmacy team. This team also ensured the service was made aware of any changes to national guidance or national alerts in relation to medicines.

Staff reported errors and incidents relating to medicines and the service took action in response to these to minimise the risk of recurrence. In the 12 months preceding our inspection staff reported 37 medicines related incidents, none of which resulted in harm to people using the service. Team meeting minutes evidenced that staff were reminded about issues identified from reported medicines incidents, for example unsigned prescriptions.