The Recovery Lodge

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the service management and leadership was inconsistent. Governance processes were not robust.

The service was in breach of Regulation 17 – good governance.

We have not awarded this service a score for Well-led.

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

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff told us they were proud of the work they did to help people to recover from addictions.

Staff had the opportunity to contribute to discussions about the strategy for the service, especially where the service was changing. Staff were able to provide suggestions and feedback through team meetings and one-to-one supervision. Staff told us they could speak with the registered manager at any time to put forward ideas and felt they were listened to.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered manager had a good understanding of the service. They could explain clearly how the team worked to provide high quality care. The registered manager had the skills, knowledge and experience to perform their role. They were a qualified counsellor and a registered member of the British Association of Counselling and Psychotherapy.

The registered manager was visible and approachable to people and staff. They worked at the service 5 days a week, including on a Saturday. Staff told us they felt well-supported.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

People and their relatives had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Between January 2025 and June 2025 the service had received 45 completed questionnaires from people and 6 from relatives. The registered manager reviewed and analysed the responses and was encouraging more families to provide feedback. An overview of outcomes was shared with staff and also at board meetings. Responses were positive. Where suggestions had been made to improve the quality of service delivered these had been listened to and acted on. For example, a suggestion for more organised recreational activities at a weekend had been made and local walks had been introduced.

Staff told us they felt listened to and would not hesitate to speak up or report any concerns.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff were able to apply to work flexibly and / or update their working patterns to account for personal circumstances such as caring or family responsibilities.

Protected characteristics were respected and the registered manager put reasonable adjustments in place for staff members to help them carry out their role.

All staff received training in the Equality Act 2010, and diversity and equality.

Staff we spoke with did not have any concerns regarding equality and diversity and felt they worked well together as an inclusive team.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance.

The registered manager completed quality monitoring checks. However, these lacked detail and had not identified shortfalls found during this assessment. For example, the entry for care plans noted, ‘currently up to date and relevant information is included’. We found relevant information was not included and the care plans were generic with many parts of the care plan being identical in every person’s plan. They were not holistic and person-centred, each person had the same goals documented.

The registered manager completed weekly medicines audits. However, these were not detailed. For example, it had not been identified that there was no process in place to monitor the temperature in areas where medicines were stored in line with best practice.

The service used a breathalyser to measure alcohol levels, however when turned on, this showed that the calibration had expired. There was a risk that readings would be inaccurate. Following the assessment the registered manager confirmed that the breathalyser had been replaced and that they purchased new equipment yearly.

Other checks, such as the environment, fire and first aid equipment and data protection were completed to ensure they were in good working order and in line with good practice.

There was a clear framework of what was discussed in team meetings to ensure that essential information, such as learning from incidents and feedback from people using the service, was shared and discussed. Admissions, incidents / accidents, safeguarding, house meetings and discharges were standard agenda items for discussion in team meetings.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including CCTV and the telephone system, worked well.

Information governance systems included confidentiality of records.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The registered manager and staff engaged with external health care professionals, such as people’s GP and the local authority safeguarding team.

Staff could meet with members of the provider’s senior leadership team to give feedback. One staff member told us, “(A non-executive director) does supervision and it is good. It is nice to be with someone a bit independent and not someone I work with every day. I would definitely go to them if I had any concerns. I feel comfortable to talk to them and raise any concerns if I needed to.”

We scored the service as 2. The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation.

The service did not focus on continuous learning and improvement. Lessons had not been learned from previous shortfalls regarding medicines management and we found medicines management remained a concern at this inspection.

The registered manager analysed feedback received from people and their relatives. Suggestions made to improve the service were listened to and acted on. For example, following feedback the service had begun trialling assigned counsellors to improve continuity.

Feedback was shared with staff at weekly team meetings and shared with the senior leadership team at board meetings.