Primrose Lodge

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people’s needs were met through good organisation and delivery.

This service scored 75 (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 Responsive.

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

Description: We make sure people are at the centre of their care and treatment choices and we decide, in partnership with them, how to respond to any relevant changes in their needs.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Staff involved clients in decisions about their care. Client voice was evident within the care plans we reviewed.

Staff held a weekly community meeting to get feedback and suggestions from clients.

Clients we spoke with felt involved in their treatment. They felt there were lots of opportunities to offer feedback to staff on an individual and group basis.

Description: We understand the diverse health and care needs of people and our local communities, so care is joined-up, flexible and supports choice and continuity.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Staff supported clients to maintain contact with their families and carers. Clients were encouraged to go off site with visitors on Sunday afternoons. Staff also held a group for family members to attend on a Sunday afternoon. Family members told us they found this support really valuable in helping them to understand their loved ones’ recovery.

Staff supported clients to access their chosen place of worship within the community.

The service joined up with other services to ensure continuity in people’s care and treatment. They involved people’s mental health teams in their care where applicable and also had good working relationships with local housing support providers who could provide interim accommodation for clients prior to them being discharged home.

Description: We provide appropriate, accurate and up-to-date information in formats that we tailor to individual needs.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff made notifications to external bodies as needed. The registered manager had submitted 30 notifications to CQC in the 12 months prior to the inspection. The manager kept a log of whether incidents were notifiable to CQC and updated this with notification reference numbers once the notification had been submitted.

Information governance systems included confidentiality of client records.

Staff ensured that clients could obtain information on treatments, local services, clients’ rights, how to complain and so on. Staff provided clients with a comprehensive welcome pack on admission. This included information about sleep and mindfulness, contraband and restricted items, families being able to visit on Sundays, meals, how to make a complaint, the weekly schedule and details of their first therapy assignment.

Staff made information leaflets available in languages spoken by clients.

Staff supported families and offered a weekly support group they could attend to learn more about addiction.

Staff ensured families were regularly updated about clients’ progress. Relatives told us that communication from the service was very good.

Description: We make it easy for people to share feedback and ideas or raise complaints about their care, treatment and support. We involve them in decisions about their care and tell them what’s changed as a result.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

Staff made clients aware how to raise concerns about the service. This was included in the client information pack and staff also displayed posters in communal areas.

The service had received 6 complaints in the 12 months prior to the inspection. The majority of these related to people requesting a refund following self-discharge from the service.

When clients complained or raised concerns, they received feedback. Staff displayed a “you said, we did” board in one of the communal areas of the service. Although, this had not been updated for over a month.

Staff protected clients who raised concerns or complaints from discrimination and harassment.

Staff knew how to handle complaints appropriately.

Staff received feedback on the outcome of investigation of complaints and acted on the findings.

Description: We make sure that everyone can access the care, support and treatment they need when they need it.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

Staff ensured the needs of clients with mobility issues were met – for example, wheelchair users were placed in the accessible bedroom. Some of the upstairs rooms at the service were also accessible via lift – staff told us that clients’ mobility needs would be considered when assigning these rooms.

Staff made reasonable adjustments for clients – for example, people with mobility issues were provided with a shower chair. Where the service was unable to meet mobility needs, e.g. if there was more than one wheelchair user, they recommended that clients were admitted to one of the provider’s other locations.

Two doctors were on call 24 hours a day to offer advice to staff, however they did not attend the service in person. Staff called 999 or 111 if they had concerns about a client’s health or if the doctors advised them to do so. The service was within a reasonable travelling distance to the local acute hospital. Staff used a local taxi company to help transport patients to hospital if needed.

Staff ensured clients had access to post-discharge care. Clients had access to aftercare at the service for a year after discharge. This was a weekly meeting at the service. Clients who were not local to the service were able to join virtually.

Staff planned for clients’ discharge, including good liaison with care managers/co-ordinators.

Discharge was never delayed for other than clinical reasons. There were no delayed discharges in the last 12 months.

Description: We actively seek out and listen to information about people who are most likely to experience inequality in experience or outcomes. We tailor the care, support and treatment in response to this.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff within the service and the wider organisation promoted a culture in which the people using the service felt empowered to give their views. Staff held a weekly community meeting where clients were encouraged to give feedback about all elements of the service provided.

The provider had undertaken equality impact assessments of some of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage.

Staff were trained in equality and diversity.

Description: We support people to plan for important life changes, so they can have enough time to make informed decisions about their future.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future.

Staff liaised with clients to plan for the future. We saw evidence in care records that staff discussed discharge planning and next steps with clients.

Staff regularly reviewed care plans in terms of clients’ treatment goals and objectives for discharge, or the transfer of care to a different service, where appropriate.

There were processes in place to facilitate the planning and delivery of discharge or transfer of care and staff worked well with other professionals to ensure clients could access the services and support they needed. Staff ensured clients referred themselves to their local community substance misuse service to ensure they continued to receive support following discharge from the service.