Primrose Lodge

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

This service scored 67 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We have not awarded this service a score for Effective.

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

Description: We maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

Quality Statement Score: 1

We scored the service as 1. The evidence showed significant shortfalls. The service did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health needs with them.

We looked at 6 care records during the inspection and found that staff completed care plans and risk assessments for all clients shortly after admission and that these were regularly reviewed.

Of the 6 care records we reviewed only 1 contained a summary from the client’s GP. All of the clients had consented to staff contacting their GP to request this information. It had been requested for 4 clients but missed for 1. This meant that for 5 clients, staff were relying on the client self-reporting information to them to make a clinical decision regarding admission.

Staff asked people questions about their mental health as part of the initial assessment, but we found entries around mental health needs to be inconsistent. For example, one client said they had been diagnosed with depression but that they were not taking medicine for this, despite having brought in some anti-depressants with their medicines which staff had continued to prescribe. There was no evidence that this had been discussed further with the client to ensure they knew why they had been prescribed that medicine.

In 3 clients’ records it stated that they had brought in medicines for various conditions but there was no evidence that this had been discussed as part of their physical health assessment with the service, and nothing noted in their risk assessments or care plans around these.

Description: We plan and deliver people’s care and treatment with them, including what is important and matters to them and in line with legislation and current evidence-based good practice and standards.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff provided a range of care and treatment interventions suitable for the client group. The interventions were those recommended by, and were delivered in line with, guidance from the National Institute for Health and Care Excellence (NICE). The service delivered a 12-step programme alongside dialectical behaviour therapy (DBT). They also provided alternative therapies every day, such as breath work and gong baths.

Staff ensured that clients had good access to physical healthcare, including access to specialists when needed. If staff were concerned about a client’s physical health they would contact the doctor and then support clients to access NHS services as indicated. Staff also supported clients to attend regular appointments as needed, for example a client had been supported to attend regular chiropractor appointments during their treatment.

Staff participated in clinical audit and had a comprehensive auditing programme in place which included topics which were audited on a daily, weekly, monthly or quarterly basis. These then fed into a monthly report for assessing overall quality.

Staff were experienced and qualified and had the right skills and knowledge to meet the needs of the client group.

Managers provided new staff with appropriate induction. New staff were given the opportunity to shadow more experienced members of the team. Therapists told us they were well supported through their induction and that they were required to complete a learning log at the end of each day which they discussed with their supervisor. Managers provided new staff with an appropriate induction.

Managers provided support staff with supervision every 6 weeks, to reflect on and learn from practice, and for personal support and professional development. Therapists received individual and group supervision every month. The organisation’s Head of Therapy also carried out monthly caseload reviews as well as observing staff deliver therapy every quarter. The percentage of staff that received regular supervision was 100%. Records showed that staff only missed supervision sessions if they were on long periods of leave, e.g. paternity leave.

Managers ensured that staff had access to regular team meetings. These took place every week and minutes were shared for any staff unable to attend.

The percentage of staff that had received an appraisal in the last 12 months was 100%.

Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge.

Description: We work effectively across teams and services to support people, making sure they only need to tell their story once by sharing their assessment of needs when they move between different services.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff held regular team meetings. They had a monthly staff meeting to discuss clients, incidents, learning from experience, community feedback, medication, recruitment, and issues pertinent to each staff group.

Staff shared information about clients at effective handover meetings within the team. Therapy and support staff had twice daily handovers, in addition to the handovers support staff had at the start/end of each shift.

The teams had effective working relationships with other relevant teams within the organisation. For example, staff demonstrated a positive working relationship with the organisations’ central admissions team, their senior managers and maintenance staff.

The teams had effective working relationships with some teams outside the organisation. Managers escalated concerns and raised issues with the local authority’s safeguarding team when needed. They also had positive working relationships with housing and support services, who fed back that staff were always very accommodating if they needed to visit clients on site. However, staff at the local acute hospital reported that they did not have a working relationship with the service and were concerned about the severity of needs some clients from the service presented at the acute hospital with.

Description: We support people to manage their health and wellbeing so they can maximise their independence, choice and control, live healthier lives and where possible, reduce their future needs for care and support.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff supported clients to live healthier lives – for example, by promoting good sleep hygiene. Catering staff ensured that healthy meals and snacks were provided for clients.

Service activities helped promote a healthy lifestyle for clients. The service had a gym which clients could use once they had completed a week in treatment. They also provided activities such as yoga and mindfulness to help clients to relax.

Description: We routinely monitor people’s care and treatment to continuously improve it and to ensure that outcomes are positive and consistent, and that they meet both clinical expectations and the expectations of people themselves.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff provided after care for clients which involved contacting them at regular intervals after they had been discharged from the service. Of the clients who had been discharged from the service in 2024, 87% of those who the service was successfully able to contact a year after discharge had remained sober. All of the clients who had completed an exit survey in 2025, agreed that their treatment was a good long-term investment for their recovery.

Staff used technology to support clients effectively. For example, the clients’ records were stored electronically which enabled easy access to information.

Description: We tell people about their rights around consent and respect these when we deliver person-centred care and treatment.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

The service provided care for clients who could consent to treatment. Staff supported clients to make decisions on their care for themselves. We observed staff encouraging a client who came in for assessment to sleep prior to proceeding with the assessment, due to them being heavily intoxicated and staff having concerns about their capacity to consent.

Staff assessed and recorded capacity to consent. They discussed information sharing with each client at the point of admission, such as for sharing treatment information with their GP. The interventions were designed to involve clients’ families and staff established consent at the beginning of treatment to contact and share information with family members, as each client deemed appropriate. We reviewed the care records of 6 clients and saw in all of them evidence of assessment of mental capacity and evidence of consent to treatment and sharing of information.

Training records showed that all staff were up to date with training in the Mental Capacity Act. Staff had a good understanding of the five principles and knew where to get accurate advice on the Mental Capacity Act.