The Care Quality Commission
  • Community
  • Community substance misuse service

Luton

Overall: Requires improvement read more about inspection ratings

17-21 Hastings Street, Luton, Bedfordshire, LU1 5BE

Provided and run by:
PCP (Luton) Limited

All Inspections

During an assessment of Residential substance misuse services

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.

During an assessment of the hospital overall

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.

09 August 2023

During a routine inspection

Our rating of this service went down. We rated it as requires improvement because:

  • The premises were not clean. Staff had not made sure cleaning records were up-to-date and the weekly cleaning checklist was last completed on 23 July 2023. At the time of inspection there was a pest control issue.
  • It was unclear if there were assigned bathroom and toilet facilities for males and females in the detoxification house.
  • Managers did not have audit processes in place to ensure that observations were being carried out in line with the provider’s policy. Staff were not always recording observations in line with the providers policy.
  • Staff did not record comprehensive care plans for each client on the electronic recording system. Staff did not regularly review or update care plans when clients' needs changed.
  • Managers were not adhering to the audit schedule. We could not be assured that staff took part in clinical audits, benchmarking and quality improvement initiatives.
  • Managers had not ensured that staff had received Mental Capacity Act training, staff had not received basic life support training in line with the providers observation policy.
  • Staff did not plan for clients’ discharge in line with the providers admission, treatment planning and discharge policy. Staff did not plan for early unexpected exit from treatment with clients.
  • Managers had not followed the providers recruitment policy.
  • Team meetings were not taking place regularly.

However:

  • The service had enough staff. Staff had received mandatory training and had access to regular supervision and handovers. Staff worked well together as a multidisciplinary team and relevant services outside the organisation. Staff felt positive and proud to work for PCP as an organisation.
  • Staff completed comprehensive assessments with clients on admission. They provided a range of treatments suitable to the needs of the clients. The service offered a full range of treatment groups and activities seven days a week.
  • Nursing staff carried out physical health assessments with clients on admission and regularly thereafter. Any identified needs were appropriately referred. Emergency equipment at both the treatment centre and detoxification house was in date, regularly tested and ready for use.
  • The service offered daily activities and therapies alongside 12-step treatment. Interventions offered included training and work opportunities.

07/11/2018

During a routine inspection

We rated Luton as good because:

  • Emergency equipment at both the treatment centre and detoxification house was in date, regularly tested and ready for use.
  • At the time of inspection there were no staffing vacancies. Between August 2017 and July 2018 there were no unauthorised absences or sickness days taken by staff. Overall, 100% of staff had completed an induction and mandatory training.
  • All clients had an initial risk assessment, all risk assessments were up to date and included what process to follow for a client who unexpectedly exited treatment. Risk management plans were individualised. All client files contained a full assessment of the client’s history and previous treatment. The doctor completed thorough medical assessments at the point of a client’s admission for treatment including a physical health examination to ensure suitability for detox.
  • Staff received feedback from incidents, both local to Luton and PCP nationwide during twice daily handovers and team meetings. Staff could tell us about changes and learning from incidents.
  • Staff reviewed and updated individual treatment plans regularly. Treatment plans were holistic, personalised, recovery orientated and looked at a client’s strength areas.
  • The service offered daily activities and therapies alongside 12-step treatment. Interventions offered included training and work opportunities.
  • All clients accessing treatment were temporarily registered with the local GP surgery for any healthcare needs. Clients were offered support to access the dentist, opticians, smoking cessation, sexual health and genitourinary medicine clinic. The service developed information-sharing processes and joint-working arrangements with other services including the local genitourinary medicine clinic, GPs and dentists.
  • Staff had a minimum of quarterly line management supervision, counsellors also participated in monthly clinical supervision with an external supervisor. All eligible staff had a recent appraisal completed. Staff had access to bi-weekly team meetings and daily handovers.
  • Clients we spoke with told us they felt empowered in their treatment. Clients said staff were caring, respectful and supportive.
  • Staff encouraged family feedback. Families could be involved in treatment progress with client agreement.
  • The service had a robust process in place for managing complaints. Clients knew how to make a complaint.
  • Staff were passionate about reducing the stigma attached to people who use substances, supporting them to recover from their illness and realise their potential. Staff felt respected, supported and valued by their peers and by management. Staff felt positive and proud to work for PCP as an organisation and they had been able to implement new groups.

However:

  • Communal rooms, one-to-one rooms, bathrooms/ toilets at both the detoxification house and the treatment centre were not fitted with alarms and staff were not using lanyard alarms.
  • Some clients had not been offered a copy of their treatment plan.
  • Some clients said they would benefit from more one-to-one sessions.

01/03/2017

During an inspection looking at part of the service

We do not currently rate independent standalone substance misuse services.

We found the following areas of good practice:

  • The service had a well-equipped, clean and tidy clinic room.

  • Staff monitored and recorded the room temperature daily.

  • The service had access to naloxone (used to reverse the effects of opioids) and a defibrillator. Staff carried out weekly audits of emergency equipment.

  • Overall, 100% of staff had completed mandatory training.

  • All clients had an initial risk assessment and all risk assessments had been updated within the past month. Risk assessments were comprehensive and included what process to follow for a client who unexpectedly exits treatment.

  • The service had robust processes in place for medicines management and administering medication.

  • Staff we spoke with were aware of what constituted an incident and how to report an incident. Staff received feedback from incidents and were able to tell us about changes and learning from incidents within the service.

  • We observed staff interacting with clients in a kind, considerate and caring manner.

  • Clients we spoke with told us staff were interested in their wellbeing and that staff were respectful, polite and compassionate. Clients said they felt safe while using the service, and were happy with the treatment they were receiving.

  • All clients we spoke with said they were involved in and offered a copy of their treatment plan. Staff reviewed and updated individual treatment plans weekly. Treatment plans viewed were holistic, personalised, recovery orientated and looked at a client’s strength areas.

  • Families could be involved in treatment with client agreement. The service facilitated monthly family meetings. Family members were asked for feedback about care and treatment.

  • Staff completed comprehensive assessments on the day of admission. The doctor completed medical assessments at the point of a client’s admission for treatment; this included a physical health examination to ensure suitability for detox. The nurse undertook physical health checks including blood pressure, breathalysing, and urine testing.

  • Staff were inducted to the service appropriately. All staff working within PCP Luton were regularly supervised and all eligible staff had a recent appraisal completed. Staff had access to bi-weekly team meetings, monthly group supervision and daily handovers. Staff had access to specialist training for their role.

  • The service rarely cancelled appointments or groups due staff shortages or sickness.

  • Facilities were available at the treatment centre so that clients could make a hot or cold drink when they wanted to. Lunch was ordered and delivered from a local café.

  • The service received 80 compliments in the 12 months prior to inspection.

  • Clients knew how to complain; in addition information about making a complaint was displayed in the seating are of the treatment centre, along with a comments box.

However, we also found the following issues that the service provider needs to improve:

  • The blood pressure machine and alcometer ( used to measure level of alcohol in breath) had not been calibrated.

  • The service had not completed a ligature audit for the treatment centre.

17 – 18 August 2015

During a routine inspection

We do not give a rating for specialist services. We found action was required because:

  • The service had no system to report incidents, harm, or risk of harm effectively. There were three incident reports available, all of which had been completed by the registered manager and lacked detail of the adverse events.
  • Learning from incidents and complaints was not shared amongst the team because there was no robust system for reporting.
  • Serious incident requiring investigation (SIRI) was not available during the inspection as it was locked in a drawer. The registered manager did not have access to the information.
  • The service did not use robust recruitment processes. References were not appropriate and did not meet the requirements of the service policy. Two references were required and in all files, one reference had been sought prior to employment. DBS (Disclosure and Barring Service) forms had not been assessed for potential risk of employing candidates and one form was incorrect.

However:

  • Recent changes to the service had been implemented with a positive effect such as the recruitment of a nurse and a compliance manager.
  • People who use the service were positive about the care.

19 March 2013

During an inspection looking at part of the service

On this occasion we were not able to speak with anyone who used the service about the way their medicines were managed.

People were protected against the risks associated with medicines because the provider had improved arrangements in place to manage medicines.

22 February 2013

During an inspection in response to concerns

We spoke with two people using the service. They told us that they were satisfied with the arrangements for their medicines and that they received their medicines on time. They told us that staff had explained what any newly prescribed medicines were for.

Although the people we spoke with were satisfied with the arrangements for their medicines, we found evidence from the inspection of medicines records and supplies that people were not protected against the risks associated with medicines, because the provider did not have appropriate arrangements in place to manage medicines.

19 December 2012

During an inspection in response to concerns

We visited PCP Luton on 19 December 2012 to follow up on concerns that had been raised by an anonymous source with regards to staff training and competencies. As part of this inspection we reviewed training records, spoke with the provider, three staff and six of the people using this service at that time.

People using the service, without exception, spoke very positively about the staff who they said were very knowledgeable, understanding and confident. When comparing PCP Luton to other substance misuse services, one person said, "It's been fantastic, life changing, the quality here is unbelievable. You don't have to fight for a counsellor's time and their knowledge is far superior."

We found the staff we spoke with were confident in their respective roles, and they told us they felt well supported and appropriately equipped to support people using the service safely and effectively. Training records and certificates that we saw confirmed that staff had attended both mandatory and role specific training.

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15 July 2012

During a routine inspection

During our visit on 17 July 2012 we spoke with four of the 13 people who were receiving treatment at PCP Luton at this time.

Three of the four people told us they had received good information about the service either on or prior to admission, and acknowledged that the PCP website was very informative and had been helpful to them. The fourth person told us that their family had arranged the treatment for them and had accessed the necessary information about the programme without any problem.

The people that we spoke with described a strict contract and timetable of treatment and support, but said they recognised this was an important part of their treatment. People said that where possible, they were given choices, but understood that the ethos of the programme involved some restriction on choices for the treatment to be effective, particularly in the early stages of the programme. People described being given more responsibility and opportunities to make personal choices as they progressed through their treatment.

People were involved in planning their care, and one person told us 'I can't fault the programme or the quality of the treatment; I know exactly what is in my care plans and I wouldn't have signed them if I didn't agree with them.'

People were satisfied with their treatment, and complimented the staff who supported them. One said. 'I have great admiration for the staff, I've been very impressed with them all'. Another person told us 'The counsellors are very good; they are fully equipped to understand what I'm going through. I 'm very happy with the programme'. They said they were always treated with respect by the staff.