Reset Treatment and Recovery Support Service - Tower Hamlets

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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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

The service had systems and processes that supported safe care and treatment, and staff understood their responsibilities in managing risk. People told us they felt safe using the service, and most referrals were triaged promptly. Pathways were documented, including prison release referrals, and leaders maintained oversight through governance meetings.

Patient Group Directions (PGDs) were incomplete, some expired and signed retrospectively, and there was no clear list of authorised staff, as required by law. The environment did not consistently protect privacy: conversations could be overheard, between rooms. Caseloads were high, affecting timely interventions despite sufficient staffing and specialist roles.

Audits showed high compliance with prescription security and benzodiazepine prescribing standards. Policies and SOPs were in place, naloxone was offered routinely, and opioid substitution and alcohol detox pathways followed national guidance.

Safeguarding training compliance was high, and staff contributed to multi-agency arrangements. However, oversight required improvement: one record lacked follow-up, safeguarding was not a standing agenda item, and 183 reviews were overdue, although measures to address this were in place.

Some areas for good practise development were identified. Patient Group Directions (PGDs) were incomplete, some expired and signed retrospectively, and there was no clear list of authorised staff, as required by law. The environment did not consistently protect privacy: conversations could be overheard between rooms. Caseloads were high, affecting timely interventions despite sufficient staffing and specialist roles.

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.

There was evidence of sustained incident reporting over the review period. The incident log recorded 134 incidents between September 2024 and September 2025, with 112 closed and 22 open at review; the average time to close an incident was 60 days. Staff described an open learning culture supported by regular morning briefings, learning and development sessions and governance meetings; we corroborated this in records, which also showed leaders using these forums to review incidents and communicate changes.

The profile of incidents supports a learning focus on medicines safety and risk management. Medication incidents accounted for 62 of 134. Within this theme, 26 related to loss, 18 to prescribing, and 16 to administration or supply; there was one medicines-management incident and one overdose recorded. Acts or threats of violence or aggression accounted for 18 incidents: 13 verbal and 5 physical. Deaths accounted for 32 incidents. The service also recorded 7 medical emergencies, 6 data breaches, 5 security incidents, and single incidents in each of the following: dangerous occurrence, environment or infrastructure, clinical, and accident at work. Lost or stolen items featured within medicines incidents: 16 "prescription lost/stolen" and 10 "medication lost/stolen".

Leaders and staff took specific actions to address risk and share learning. For medication-related risks, records show teams cancelled prescriptions, contacted pharmacies and re-issued prescriptions where appropriate; for safety events they used de-escalation and reinforced zero-tolerance messaging; for lost or stolen prescriptions or medicines, people were asked to make police reports and provide a crime reference number while staff cancelled scripts and alerted pharmacies. Strategic Leadership Meeting minutes showed senior oversight and responsive change: following a lost-prescription incident, leaders updated the pathway and shared it via morning brief and internal systems. Recording actions and associated learning in governance systems enabled leaders to check whether improvements had been shared and embedded. This supported consistency across teams and helped maintain safer care over time.

Incident reporting remained well embedded, and staff described a positive learning culture supported by daily briefings, learning and development sessions and governance meetings. Records showed that leaders used these forums to review incidents and share changes. The incident log demonstrated sustained reporting and oversight. However, staff described frequent verbal and racial abuse and one recent physical incident. Managers sometimes reallocated clients rather than applying clear consequences, and staff were not always informed of plans after serious threats.

We reviewed the quality of recording in the “What did we learn & what actions have been taken” field. While many entries included clear actions, some incidents lacked a record of the action taken or the associated learning. Improving the consistency of recording would strengthen assurance and help evidence how changes were embedded. Other details, such as grading and documentation of apologies, were variably recorded. These inconsistencies did not undermine the overall systems in place but indicated areas where documentation could be strengthened to support clearer oversight.

Staff followed safe and consistent pathways into the service. Referrals were received electronically, tracked and triaged within three days. Since September 2024, of 315 new service users, 215 were seen the same day and 69 within one day, demonstrating timely access for most people. Assessments were flexible and responsive to individual needs, offered by phone or at home where appropriate. Continuity was maintained by allocating the same worker from assessment into case management. People told us staff explained consent and treatment options clearly, involved relatives appropriately and shared medicines information. Pathways were documented, including prison release referrals and criteria for complex case allocation. The provider had developed a Respiratory Disease in Drug and Alcohol Treatment Services: Clinical Pathway and a Mental Health Service Map, which listed local services such as the diagnostic memory clinic and community learning disability service.

Leaders had oversight of clinical transitions and monitoring. Monthly Clinical Practice Meeting minutes showed annual reviews were discussed and actions recorded. Weekly nurse meetings were used to track electro cardiograms (ECGs) due or overdue, book appointments and monitor completion. A clinical practice group introduced in July 2025 aimed to improve oversight and embed safety conversations. Observation confirmed ECGs were completed by nursing staff only when clinically indicated. Staff explained that ECGs were followed up with the person present, and nurses initiated investigations and arranged GP follow-up where needed. This combination of governance, clinical and operational oversight reduced the risk of missed safety actions across disciplines.

Our review of 7 care and treatment records showed that annual health reviews were documented in five records, with one review scheduled and one not yet completed. Two people identified as requiring ECGs had had these completed. However, for 5 of the records we reviewed evidence of some health screens had not been recorded. Governance meetings demonstrated that staff discussed physical health screening and reviews and took follow‑up actions. This indicated that required checks were being completed. However, this activity was not consistently reflected in individual records. Because documentation did not always show what had been done, leaders could not fully demonstrate that all checks were recorded for each person or that all staff had access to the most up‑to‑date information.

Medicines audits carried out in October 2024 showed high compliance with prescription safety standards. Of 34 standards, 33 were met. Issues identified during the audit, including expiry date checks and authorised staff lists for prescription storage, had been resolved. Prescription administration and security compliance was 100%, and stock management was 80%. These findings support safe systems for medicines handling and demonstrate that identified risks were acted on promptly.

Benzodiazepine prescribing audits reviewed 10 care records and found 100% compliance with dose limits and prescribing of diazepam. There was evidence of dose reduction plans in all relevant cases and documented rationale for stable dose prescriptions in 84% of records. Communication with GPs was evident in 89% of cases. These findings support safe prescribing practices and clinical oversight.

An alcohol audit completed in May 2025 reviewed 8 care records. Nurse Alcohol Assessments were not completed within 10 working days in 5 cases, and 2 cases lacked an opened Alcohol Treatment Plan following assessment. One record lacked evidence of harm reduction advice, and 2 lacked documented MDT-agreed timescales. The provider has initiated a second-line audit and scheduled governance meetings to address these findings.

Staff demonstrated a clear understanding of their safeguarding responsibilities and were confident in identifying signs of abuse and neglect in both adults and children. They sought consent appropriately and explained safeguarding processes to people in a way that helped reduce fear and build trust. Staff were aware of the boundaries of confidentiality and consistently discussed safeguarding concerns with the individuals involved. This supported people to feel safe and informed about decisions affecting them.

Mandatory training compliance in safeguarding adults, safeguarding children, the Mental Capacity Act (MCA), and Deprivation of Liberty Safeguards (DoLS) was consistently high, with rates above 96%. Staff had access to safeguarding information on-site, including leaflets about keeping children safe, which supported awareness and promoted a safeguarding culture. These measures ensured staff had the knowledge and resources to recognise and respond to safeguarding concerns effectively.

Staff contributed to multi-agency safeguarding arrangements, including participation in Multi-Agency Risk Assessment Conferences (MARAC), child protection and child in need meetings, safeguarding adults’ boards, domestic homicide reviews, and local suicide prevention groups. This collaborative approach supported timely and appropriate responses to risk and helped protect people from avoidable harm.

We reviewed 7 care records and found that in almost all cases, staff had appropriately shared safeguarding information with relevant external agencies. In one record, a safeguarding flag had been added on the clinical system, relating to the perceived risk that a take‑home opiate prescription could pose to children in the household. Safe storage was recorded as having been provided. A later review showed that the flag had been removed after the person was assessed as stable and no longer posing a risk. However, the record did not clearly explain why the case had been flagged as safeguarding or how the decision to remove the flag had been reached. The lack of a clear rationale reduced assurance because staff reviewing the record could not see the basis for the safeguarding categorisation or its removal.

Performance assurance meeting minutes showed that there were 183 overdue safeguarding reviews where cases had been highlighted as ‘cases of concern’. The provider’s response was to address these through case management reviews. This demonstrated that leaders had identified gaps in safeguarding oversight and had taken steps to improve monitoring and accountability.

Staff involved people in identifying and managing risks and used collaborative approaches, including motivational interviewing and escalation to the multidisciplinary team or senior staff when concerns increased. Most people told us they took part in care reviews and felt involved in decisions about their care. Staff understood and applied the service policy to contact people at least every 28 days, with frequency adjusted based on individual risk. Harm reduction advice was consistently documented in care records, and we saw evidence of information sharing with partner agencies to support safe care.

In our review of 7 care records, 6 contained a risk assessment.

We saw routine contact and reviews for most people, and staff could describe how they applied the 28‑day contact policy. Strategic leadership meeting minutes confirmed that the “28 days no contact” issue had been discussed, with proposals to create a bi‑weekly space to support staff in addressing gaps in engagement and delivery. The intention was to frame this as a case management support session, with mandatory attendance, to protect safe delivery and support the workforce. Performance assurance meeting minutes showed that as of 30 June 2025, 90 individuals had not been contacted in over two months. This was a standing agenda item for team leaders to action through case management reviews. The provider’s improvement plans included monthly case management reviews every four to six weeks to ensure team leader oversight and a feedback loop into wider leadership. It also introduced monthly “over 28‑day” case support sessions in April 2025 to improve retention and oversight of quality. These actions showed that leaders had identified the risk of missed contact and implemented structured oversight to address it.

The provider has improved the premises and equipment to support safer care. In January 2023, it increased clinical capacity by creating five additional one-to-one rooms, a clinical room and two urine drug-screening toilets. Staff tested new panic alarms and emergency pull cords during drills. We saw clear safety signage and visible fire exits. A defibrillator and evacuation chair were accessible. Training records showed high compliance with core health and safety subjects (98–100%). Managers scheduled hazardous waste collections and held regular health and safety meetings covering first aiders, fire wardens, audits and premises checks. Fire alarm test logs and inspection certificates were in date, which assured that emergency systems were routinely checked. People told us they felt safe and described the environment as warm and clean. Some suggested more comfortable furniture, additional seating and soundproof rooms for acupuncture. The provider installed automated Legionella testing and introduced phased first aid training for all staff. Staff held health and safety lead roles, and the service had a local first response procedure.

However, the environment did not consistently protect privacy and confidentiality, Provider records showed that concerns about noise and acoustic transfer had been raised and discussed. During the inspection, we heard noise carry between rooms, and people using the service told us they had overheard conversations. We did not see an environmental risk assessment that addressed these issues. These findings indicated that some areas of the building did not provide adequate privacy.

The main entrance had steep stairs that posed a fall risk. Although a lift was available, it was accessed via an adjoining nursery and required staff fob access. The risk register recorded accessibility as a significant risk. Staff told us the building was not the most appropriate or therapeutic, and leaders were exploring alternative premises. A central facilities team completed and maintained the fire risk assessment and an up to date copy was not available on site. . Weekly alarm tests and inspection certificates were in date.

There were enough staff to keep people safe and meet their needs. People told us staff were responsive, flexible with appointments, and available at weekends. They described staff as experienced, conscientious and forward‑thinking, and valued the contribution of those with lived experience, which supported effective communication and built trust. Staff were visible and available throughout the service, and we observed them supporting people in ways that suggested they were well trained.

Staff had access to regular supervision, weekly CPD sessions and external counselling. New staff received a protected induction period of up to four weeks, with a structured induction pack covering health and safety, key policies, training, shadowing and leadership structure. Mandatory training compliance was high, with safeguarding adults and children training completed by 98% of staff. Staff had completed a range of training including motivational interviewing, trauma‑informed care, suicide prevention, de‑escalation and basic life support. Professional registration checks were in place for clinical roles, including NMC, GMC and HCPC verification.

However, staff told us that high caseloads could feel overwhelming and affected the quality of their work. Leaders acknowledged these pressures and said they monitored caseloads through case management reviews and biweekly check‑ins, and would provide additional support where needed. The provider had increased staffing through supplementary grant funding, adding 28 roles including prescribers, nurses, team leaders and psychologists. The service had five prescribers and five nurses, with a lead nurse also covering dual diagnosis. Specialist roles supported segmentation of caseloads, including alcohol care coordinators, complex case workers and assessment staff. Recruitment was values‑based and competency‑based, with peer mentors involved in interview panels. Staff rotas were regularly reviewed, with duty workers and managers allocated. Nurses had completed phlebotomy training, which enabled blood tests to be taken promptly on site, reducing delays for people who needed urgent results. We also saw specialist roles in place, such as chemical sex and opiate workers, which supported targeted interventions.

We did not see local caseload guidance or a benchmark that set out the provider’s expected levels, so we could not assess the caseloads described against an agreed standard. Without this information, it was not clear whether the caseloads reported by staff were within the provider’s intended operating model or above the levels they considered appropriate. The provider had implemented processes to support safe allocation and oversight. A complex case criteria and allocation procedure was in place, and high‑risk clients were discussed in supervision and allocation meetings held three times per week. Staff were given protected admin time to update records, and managers prioritised high‑risk clients for review. The service improvement plan included a staffing structure review to improve staff wellbeing and service user experience, with actions underway to redistribute roles and create additional capacity.

Staff followed safe infection prevention and control (IPC) practices and understood their responsibilities in maintaining hygiene and reducing risk. People told us the facilities were clean, safe and easy to use, and no concerns were raised about IPC. We observed hand sanitisers, gloves and handwashing facilities available and in use, and staff appeared mindful of hygiene when supporting people. Staff described using gloves, wiping down surfaces and equipment, and staying home or wearing masks if unwell. They were aware of blood-borne virus risks and described safe handling of urine drug screening kits, disposal procedures, and use of bio-spill kits. Staff also reported that reminders and protective equipment were visible throughout the service, including alcohol wipes and needle exchange materials.

The provider had a comprehensive IPC policy covering personal protection, hand hygiene, specimen handling, and public health alerts. A risk assessment dated November 2024 identified hazards including needlestick injury, blood-borne virus transmission, body fluid spills, high consequence infectious diseases, Legionella, and waste. Controls included training, PPE, safe disposal procedures, ventilation, and daily cleaning. Bio-spill kits were available in reception and clinical areas, and staff were trained in their use. Hepatitis B vaccination was encouraged for all staff, and occupational health referrals were available. The provider maintained oversight through monthly premises inspections, six-monthly health and safety audits, and daily monitoring via team meetings. Legionella checks were tracked and escalated where needed.

An IPC audit was completed in January 2025 as part of the national audit programme. The audit assessed compliance against 73 standards and found that the site met or exceeded expectations in all areas. Whitechapel Road achieved 100% compliance in governance, staff immunisation, clinical environment, equipment, drug testing rooms, hand hygiene, waste management, sharps management and general environment. Decontamination of the environment scored 89%. Cleaning specifications were met, and findings were escalated to the cleaning company for quarterly review.

Staff reported that bins in urine testing rooms were sometimes full and that clinical waste disposal could be improved. The provider confirmed that cleaning is outsourced under a national contract and provided the site cleaning specification. Fridge temperature checks were recorded daily on the case management system, and sharps bin cleaning occurred fortnightly. All audits were logged on the provider’s governance system.

IPC risks were reviewed every six months. Staff could escalate concerns via incident reports or through team leaders, who liaised with cleaning contractors. Training compliance was monitored through the provider’s learning system, and staff were reminded to maintain hygiene standards. The provider had identified IPC as a priority area and had systems in place to ensure oversight, respond to risks, and maintain safe environments.

The service ensured people received safe medicines support that met their needs, capacities and preferences. Staff involved people in planning their treatment, including when changes were required. Medicines and controlled stationery were stored securely, and appropriate audit trails were maintained. Clinical administrators printed prescriptions at the request of a prescriber and ensured these were signed before being given to the person or sent to a pharmacy. Void prescriptions were managed appropriately.

Access to medicines storage areas was restricted, and staff completed monthly checks to review storage and cleanliness. Medicines were stored securely on the premises. On the day of the inspection, the temperature monitoring records available showed gaps, which did not align with recommended guidance. We did not review the provider’s temperature‑monitoring policy during the inspection. The provider subsequently shared a link to the site’s clinical temperature monitoring log, which showed completed temperature checks.

Service users were provided with a medicines safe to support secure storage at home. They were also given access to naloxone with appropriate information on how to use it. Naloxone was offered at every subsequent visit, with supplies provided as needed.

Staff discussed medicines and treatment progress in multidisciplinary meetings. They obtained people’s consent to share information with their GP and could access medical histories to complete medicines reconciliation prior to prescribing. People without a GP were supported to register with one. Staff reported that they wrote to GPs to request that certain medicines were not prescribed while individuals were receiving treatment through the service.

The service had systems to manage medicines safety alerts and incidents. Medicines incidents were recorded electronically, enabling analysis and shared learning through the monthly Information Governance Team meetings. The provider’s clinical governance team cascaded medicines‑related alerts to the service.

Staff reviewed people’s physical health in line with NICE guidance. Service users were offered urine drug screening on admission and throughout treatment. They were also offered blood‑borne virus testing (hepatitis B, hepatitis C and HIV). Where eligible, nurses administered the hepatitis B vaccine under a Patient Group Direction (PGD). However, PGDs in use did not meet recommended guidance, and staff using them did not have documented evidence of the required training and authorisation.