Updated 28 October 2025
Date of on-site assessment, 14 July 2025.
PCP Luton is a residential substance misuse service, which opened in April 2005. The service provides residential rehabilitation, detoxification that includes supporting people to access the 12-Step principles of Cocaine Anonymous (CA) and Alcoholics Anonymous (AA). Statutory agencies referred people, while others self-referred and funded their own treatment. PCP Luton provided treatment for up to 13 people at a time. People engaged in 1 to 1 therapy and group therapy sessions. During our assessment, there were 12 people receiving support.
People took part in group work during weekdays and visited the community in small groups on Wednesday afternoons. At the weekends people attended meetings and if they wished, saw their families. The service provided regular follow-ups including daily text messages, check-ins and online aftercare meetings.
PCP Luton is registered with the Care Quality Commission to provide:
- Treatment of disease, disorder or injury
- Accommodation for persons who require treatment for substance misuse.
We previously inspected PCP Luton in August 2023 and rated it as requires improvement overall. Good for Effective, Caring, Responsive and Requires Improvement for Safe and Well Led.
At the last inspection we found 5 breaches of the regulation, the service was in breach of: -
Regulation 12 HCSA (RA) regulation 2014 Safe care and treatment
- The provider did not ensure staff planned for people’s discharge in line with the providers admission, treatment planning and discharge policy. Unexpected exit from treatment plans were not in place in line with the providers early unplanned discharge strategy.
Regulation 15 HSCA (RA) Regulations 2014 Premises and equipment
- The provider had not ensured all areas were clean and that cleaning records were up to date.
Regulation 17 HCSA (RA) regulation 201 Good governance
- The provider had not implemented a robust internal audit and assurance process
Regulation 18 HSCA (RA) Regulations 2014 Staffing
- The provider had not ensured that staff received basic life support training in line with the providers observation policy.
- The provider had not ensured staff received Mental Capacity Act training.
At this inspection the service is still rated as requires improvement overall. Good for Effective, Caring, Responsive and Requires Improvement for Safe and Well Led.
At this assessment we found 9 breaches of the regulation the service was in breach of: -
Regulation 12 HCSA (RA) regulation 2014 Safe care and treatment
- Bloods and Electrocardiogram (ECGs) were not always completed prior to admission where appropriate.
- GP summaries and referral information was not always known before admission.
- The clinic room lacked equipment. There was no grab bag, sink, couch or examination area.
- Environmental risk assessments were not all in place. There was no, detailed ligature risk assessment or current fire risk assessment or legionella risk assessment. Staff did not know the location of the ligature cutters.
Regulation 15 HCSA (RA) regulation 2014 Premises and equipment
- The provider had not ensured all areas were clean and that cleaning records were up to date. The furniture and decoration in the service was of a poor standard.
- The environment was not safe as there were no alarms in people’s bathrooms, toilets and communal rooms. Staff had no lanyard alarms or personal alarms.
Regulation 17 HCSA (RA) regulation 2014 Good governance
- The admission policy permitted emergency admissions without adequate clinical information.
- Leaders had not assessed, monitored and mitigated the risks relating to the health, safety and welfare of people.
Regulation 18 HCSA (RA) regulation 2014 Staffing
- Leaders did not ensure that all staff were given appropriate training for their roles.