The Recovery Lodge

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

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of Regulation 12 – Safe care and treatment.

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.

We scored the service as 3. The evidence showed a good standard. 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.

Staff knew what incidents to report and how to report them. Staff recorded incidents, including any actions taken as a result. These were reviewed by the registered manager to ensure action had been taken, if needed.

Incidents were discussed at weekly team meetings. This included any feedback from investigations, both internal and external to the service.

Staff understood duty of candour. They were open and transparent and gave people and families a full explanation if things went wrong.

Staff told us that they learned from incidents and this sometimes led to changes in practice. For example, staff would support a group of people to go to a local shop, to buy snacks, after a fellowship meeting. People were now supported on an individual basis following an incident of theft.

We scored the service as 3. The evidence showed a good standard. 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 provider had an admissions and discharge policy in place. The service’s admission process ensured that essential information about people was received to help determine if their needs could be safely met. For example, GP summaries were requested on admission and treatment summaries sent to GPs on discharge, providing the person had consented to this.

Staff provided after-care for people. Staff followed up with people 7 days, 14 days and 12 weeks post discharge. When a person had spent 28 days at the service, they were able to access the service for 4 days of after-care. Staff told us this was beneficial to people who had left and also the current group of people using the service who benefitted from hearing from people who had been discharged and successfully remained sober.

We scored the service as 3. The evidence showed a good standard. 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.

People told us they felt safe and supported at The Recovery Lodge. Staff completed training in safeguarding adults and children. Staff had a good understanding of safeguarding and gave examples of how to protect people from abuse. Staff understood how to protect people from harassment and discrimination, including those with protected characteristics, under the Equality Act. There were processes in place, which were followed by staff, to report concerns. Staff told us, in the first instance, they would raise a concern with the registered manager. They felt confident the right action would be taken to protect people. The registered manager worked in partnership with other agencies. For example, we saw evidence that the registered manager had liaised with Local Authority safeguarding teams and the Police.

Mental Capacity Act

Staff had a good understanding of the Mental Capacity Act. They discussed mental capacity in both team meetings and one-to-one supervision. All staff had completed mental capacity and deprivation of liberty safeguards training.

The provider had a policy on the Mental Capacity Act. Staff were aware of the policy and had access to it. Staff knew where to get advice regarding the Mental Capacity Act. The executive team discussed changes to policy at quarterly board meetings to ensure policies were kept up to date.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks.

We reviewed risk assessments for all 6 people admitted to the service at the time of our inspection. All people using the service had risk assessments in place; however these were not sufficiently detailed or robust. For example, in the records for one person it showed that they were at risk of a physical health issue, however there was no documented information for staff to follow about possible signs which may indicate a deterioration in physical health.

Risk assessments were generic and not tailored to individual needs. There was no indication that people using the service and their relatives had been involved in the risk assessments we reviewed.

The service did not admit people with known risks of violence or aggression. Staff did not use restraint. Staff told us they used verbal techniques to help reduce people’s anxiety levels. They told us this had always been successful.

We scored the service as 3. The evidence showed a good standard. 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 service was homely, clean, well-maintained and well furnished. People had access to outside space and therapy rooms. Therapeutic sessions were held in dedicated therapy rooms to ensure people had privacy.

People told us the environment was good. A person noted on feedback following discharge, ‘I found the accommodation very tranquil. Comfortable and very homely.’ From January 2025 to June 2025 the service had received 45 feedback questionnaires from people. Most people felt the standard of accommodation was either ‘very high or ‘excellent’.

The registered manager completed regular checks on the environment. Checks included monitoring fire safety and first aid equipment. Staff completed fire safety training. Staff reminded people of fire evacuation procedures in regular house meetings.

The service had closed circuit television (CCTV) installed in communal areas. CCTV equipment was securely housed. A data impact assessment had been completed to record the purpose and necessity of use. The service was registered with the Information Commissioners Office. A data protection and GDPR policy were in place. People were made aware of the CCTV and there was clear signage. Staff were able to view CCTV live from the office.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked well together to provide safe care that met people’s individual needs.

Staff were recruited safely and completed an induction when they joined the service.

Staffing levels were flexible. When needed the registered manager increased staff to ensure people received the support they needed, when they needed it. For example, the previous day there had been 2 new admissions, and the staffing level had been increased to ensure all the people received the right level of support.

There was a low sickness rate at the service and a high staff retention rate. The staff team worked closely and covered any sickness or unexpected absence.

There was no on-site medical cover in place. An Advanced Nurse Practitioner (ANP) was contracted to provide clinical assessments, medical oversight and detoxification planning. A pre-assessment was completed on admission to the service. Staff could contact the ANP if they had any concerns about people during treatment. Staff would contact emergency services in the event of any medical emergencies.

Therapists and counsellors worked at the service each day. Staffing levels allowed people using the service to have regular one-to-one time and group sessions.

Staff received appropriate mandatory training. However, less than 50% of staff were up to date with their mandatory training in the following areas: moving and handling of people, food safety level 2, diabetes awareness, lone working and drugs and alcohol awareness.

Staff felt supported by the registered manager and had one-to-one supervision with a non-executive director.

We scored the service as 3. The evidence showed a good standard. 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.

The service was clean and well-maintained. Cleaning staff were employed. People were encouraged to help staff keep areas of the service clean and tidy.

Staff completed infection control and food safety training and kept up to date with guidance. Staff adhered to infection control principles, including handwashing.

Staff supported people to cook and keep the kitchen and food storage areas clean. The kitchen was visibly clean and organised during our inspection.

We scored the service as 1. The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines were stored securely. However, there was no process in place for checking and recording the temperature in the areas where medicines were stored. This meant there was a risk that medicines were not stored at the recommended temperature, potentially affecting their efficacy.

An advanced nurse practitioner (ANP) used the clinical institute withdrawal assessment (CIWA) for alcohol to assess and monitor withdrawal symptoms in patients. The ANP prescribed medicines for patients using private prescriptions. However, we found that controlled drugs (CD) were not being prescribed for named individuals. These medicines were procured to be held in stock to be then administered to patients. This does not meet legislative requirements as the provider did not have a Home Office Controlled Drugs license or exemption in place to procure CDs.

Some improvements had been made for prescribing medicines and recording the administration on the medicines administration records (MAR) since the last inspection. However, further improvements were needed. The ANP handwrote the prescribed medicines on the MARs for the care staff to administer these medicines. However, clear dosage instructions were not always recorded for variable-dose CDs.

There was a process in place to report and investigate medicine incidents and errors. There was a medication policy in place. However, this required review in relation to how to procure CDs meeting legislative requirements.

Staff received training to handle and administer medicines. However, the records we reviewed showed that some members of the care staff responsible for handling medicines had not received a competency assessment for handling and administering medicines safely. The provider's medication policy stated that these competency assessments should take place annually.

No emergency medicines were on the premises. Staff told us they contacted emergency services in the event of a medical emergency.