Primrose Lodge

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of regulation 12 (safe care and treatment). At times the service had accepted clients into treatment that were too high risk for them to be safely managed in a medically monitored rehabilitation service environment that had no doctors or clinicians on site. Decisions to prescribe detoxification medicines were made without sufficient supporting information about the client’s medical history and the safety of proceeding with detoxification.

This service scored 59 (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 Safe.

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

Description: We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff kept a log of all incidents that took place, including any action taken as a result.

All staff knew what incidents to report and how to report them.

Staff reported all incidents that they should report. This included medication errors, violence and aggression, mental health concerns, physical health concerns, security issues and safeguarding concerns.

Staff understood the duty of candour. They were open and transparent, and gave patients and families a full explanation if and when things went wrong.

Staff received feedback from investigation of incidents, both internal and external to the service. Staff discussed feedback from incidents in their monthly team meetings and managers also shared a monthly ‘learning from experience’ bulletin with staff which included relevant learning from across all the provider’s services.

Description: We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care.

The service’s referral and admission processes did not ensure that all essential information about the client was received to determine if the client’s needs could safely be met. 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 about their medical history to them. This meant there was an increased risk of the doctor who admitted the client missing key information relating to a client’s medical history that could impact on their safety and wellbeing during admission, particularly when they were undergoing detoxification that has associated risks.

The service had an exclusion criteria in place, however this was not appropriate for the type of service being delivered. The criteria did not provide enough detail or guidance for the admitting clinician to refer to when admitting a person into the service. This meant there was a risk clients could be admitted to the service with higher needs than could be safely met in a medically monitored detoxification service.

Staff involved other health and social care services to ensure clients had continuity of safe care, both within the service and post-discharge. Therapy and support staff had twice daily handovers, in addition to the handovers support staff had at the start/end of their shift. Staff encouraged clients to refer themselves to their local community drug and alcohol service, to ensure continuity of support once they were discharged. Where staff had concerns about a person’s ability to look after themselves post-discharge, they made safeguarding referrals to the local authority.

Description: We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. All staff had completed training in safeguarding adults and safeguarding children.

Staff could give examples of how to protect clients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff we spoke to confidently explained what they did when they had safeguarding concerns, including exploring the concerns with the client to ensure their views were considered. Staff also knew who the safeguarding lead for the organisation was.

Staff did not allow children to visit clients at the service. If clients wanted to see children they would leave the building. Staff told us they would recommend child-friendly places to visit nearby, such as local playgrounds.

Mental Capacity Act

The service provided care for clients who could consent to treatment. Staff supported clients to make decisions on their care for themselves and recorded capacity to consent.

All staff had received training in the Mental Capacity Act.

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles.

There were no deprivation of liberty safeguards applications made in the last 12 months.

The provider had a policy on the Mental Capacity Act. Staff were aware of the policy and had access to it.

Staff knew where to get advice regarding the Mental Capacity Act.

Description: We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. The service did not always work with people to understand and manage risks. Staff did not always assess and manage risks to clients and themselves well.

We reviewed the risk assessments and management plans for 6 clients.

Staff completed risk assessments for each client before and after admission, and at key stages in the treatment pathway. The service did not admit clients with known risks of violence or aggression. Staff did not restrain clients and were trained to use de-escalation techniques to help clients when needed. If staff were unable to verbally de-escalate a client and they became physically aggressive, staff would call the police for assistance.

Staff involved clients in care planning and risk assessment both during the admissions process and on an ongoing basis with the therapy team. However, we found that 2 entries in risk assessments and care plans had been copied and posted from other entries. This was evident where incorrect names and pronouns had been used.

In 3 clients’ records 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.

Staff communicated with clients so that they understood their care and treatment, including finding effective ways to communicate with clients with communication difficulties.

Staff enabled clients to give feedback on the service they received. They held a weekly community meeting which enabled information sharing and provided an opportunity for clients to give feedback around a number of areas including housekeeping, catering, therapy staff, groups and support staff.

Staff displayed a poster about how clients could access advocacy services.

Description: We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Summarise your findings here using the topics below:

Staff did regular risk assessments of the care environment. This included a ligature risk assessment. Staff kept ligature cutters in the office.

The provider had installed CCTV footage in all of the communal areas of the service. Staff could view this live from the staff office.

The service complied with guidance on eliminating mixed-sex accommodation. All of the bedrooms at the service were ensuite. There were 2 shared occupancy rooms which could accommodate 2 clients. Managers told us that only people of the same gender would be placed in these rooms and this would be subject to risk assessment and agreement from both clients.

Staff had easy access to radio devices to communicate with one another and clients were issued with a portable alarm while they were going through the early stages of detox. Clients at higher risk of falls were also placed in a ground floor room. There was 1 room at the service suitable for a disabled person. This room was fitted with an alarm call system in the bathroom.

Managers maintained records of fire system maintenance and checks. Staff had completed fire marshal training. There was fire signage throughout the building.

However, during our inspection we observed that conversations from within the assessment room could be overheard from outside. The registered manager took action to rectify this by closing and locking the window. They planned to install air conditioning in the room to ensure the temperature was comfortable.

Description: We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

Quality Statement Score: 1

We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff.

There was no on-site medical cover in the service. Two doctors were based off site and completed virtual admission assessments, followed by a treatment plan. The doctors worked on a self-employed contract with this provider. This meant that clients were not seen in person by a clinician prior to them being prescribed medicines for detoxification, or at any point during their treatment with the service. The doctors were allocated to support clients on rotation and were able to cover each other when on leave. The provider told us that they had no plans to change their initial assessment process, but they were considering requesting doctors provide weekly drop-in sessions for clients so they could review their physical health needs.

All the staff we spoke with confirmed that they had access to advice from the doctors when needed on a 24-hour basis and we saw multiple examples of the support staff contacting doctors for advice, e.g. when a client thought they might have a urinary tract infection.

During remote assessments, support workers were occasionally asked to carry out physical examinations on direction from the doctor, which they were not trained to do. We raised this with the provider following the inspection and they confirmed that they had asked staff to immediately cease this practice, which was not in line with their established assessment process.

There were enough staff to carry out physical observations, such as checking pulse and blood pressure safely, and staff had been trained to do so. All staff had completed training in carrying out physical health observations and their competency was checked annually.

Managers had calculated the number of staff required on each shift. There were 2 support workers on shift during the day and 2 at night. This was in addition to the therapy team who were on site during the day. All roles had been recruited to.

The service had a low sickness rate (1.8% in the last 12 months) and a high staff retention rate (97.7% in the last 12 months).

Staffing levels allowed clients to have regular one-to-one time with their named therapist.

Staff shortages rarely resulted in staff cancelling planned activities. Staff told us that timetabled activities may occasionally need to be moved around or swapped, e.g. if the yoga teacher was unable to attend another activity may need to take place instead.

Staff had received and were up to date with appropriate mandatory training.

Infection Prevention and Control

Description: We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

Staff maintained equipment well and kept it clean. Two housekeeping staff worked at the service and they followed a cleaning schedule.

Most areas of the service were very clean, had good furnishings and were well-maintained. The cleaning staff frequently received positive feedback in community meetings and staff meetings. However, the communal kitchenette in the reception area had a dirty worktop and sink area. This was already included on the service’s site improvement plan and there were plans to replace this worktop by the end of October 2025. Staff also updated their cleaning schedule sheet to specifically include this area to ensure it was kept clean until the improvement works were carried out.

Cleaning records were up to date and demonstrated that the service was cleaned regularly. However, one of the daily cleaning checklists in the laundry room had already been completed for dates in the future. The registered manager addressed this by moving to an electronic form which could only be completed once the date had been reached.

The catering team were responsible for cleaning and infection control in the kitchen and food storage areas. During our inspection, we saw these areas were visibly clean and very well organised.

Staff adhered to infection control principles, including handwashing.

Description: We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Staff did not always follow best practice when prescribing medicines. Clients were asked to bring their own medicines into the service on admission and these were subsequently prescribed by the doctors so that staff at the service could continue to administer them. However, there was no record to demonstrate the reason for why the medication was prescribed and whether this had been discussed with the client as part of their medical assessment. For example, a client had been prescribed a medicine in October 2024 which staff had continued to prescribe and administer a high dose of twice per day without any record of this being discussed with the client during their medical assessment. There was no evidence that this was a current medicine as there was also no GP summary in place for this client.

Staff reviewed the effects of medication on patients’ physical health regularly.

Staff followed good practice in transporting, storing, and administering medicines, including both facility-controlled and client-controlled medicines. The medicines cabinets were well-organised and kept locked. Controlled medicine administration was accurately documented in the controlled drugs book, providing clear evidence of good compliance with legal and safety requirements.

All support staff were trained in medication management and completed annual competency checks.

Staff logged medicines errors on the unplanned events log and we saw evidence that they discussed and learned lessons to prevent these from happening again.