The Care Quality Commission
  • Residential substance misuse service

St Anne's Community Services - Alcohol Services

Overall: Good read more about inspection ratings

186 Woodhouse Lane, Leeds, West Yorkshire, LS2 9DX (0113) 243 4486

Provided and run by:
St Anne's Community Services

All Inspections

During an assessment of Substance misuse services

St Anne’s Community Services – Alcohol Services is a detoxification service and a residential rehabilitation service based in Woodhouse, Leeds. It is in the independent sector and belongs to a larger charity called St Anne’s which provides services for people with mental health issues, substance misuse and homelessness.

The service provides treatment to men and women over 18 years of age.

The service is separated into:

  • A five-bed detoxification service, which provides residential alcohol detoxification to adults who require a safe and supervised place to withdraw from alcohol. This includes clients who are stable on substitute prescriptions for opiate dependency.
  • An 18-bed residential rehabilitation service, which provides adults who have been experiencing alcohol-related problems with an intensive period of support to maintain abstinence from alcohol.

The referral route for both the detoxification and the rehabilitation services is through the community-based substance misuse services in Leeds.

We inspected St Anne’s Community Services - Alcohol Services on 7 and 8 April 2026. We assessed all 34 quality statements and rated the service as good across all domains, and good overall because:

  • The service had a proactive and positive culture of safety, based on openness and honesty. Staff knew how to report incidents and the systems in place to do so worked well.
  • There were effective referral and admission processes in place, and we found evidence of good joint working with community substance misuse and mental health services.
  • The service was very proactive in the recruitment and training of volunteers.
  • Staff understood how to protect clients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
  • Feedback from people who used the service, those who are close to them and stakeholders was continually positive about the way staff treat people. People told us that staff went the extra mile and the care they received exceeded their expectations.
  • The service had enough nursing and medical staff, who knew the clients well and received appropriate training to keep people safe from avoidable harm.
  • Leaders had a very good understanding of the services they managed and could explain clearly how teams worked to provide high quality care. Staff were extremely positive about managers and leaders, describing them as visible, supportive, and approachable.
  • Managers could describe and give examples of innovations and quality improvements initiatives which were in place and how they helped shape and improve client care.

Mental Health Act and Mental Capacity Act Compliance Summary

The service was not registered to admit people detained under the Mental Health Act. Nevertheless, Staff were trained in and had a good understanding of the Mental Health Act. 90% of staff had received training in the Mental Health Act. The provider had relevant policies and procedures that reflected the most recent guidance. Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.

95% of staff had had training in the Mental Capacity Act. Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles.

The service did not admit people who were subject to deprivation of liberty safeguards under the Mental Capacity Act. Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards. Care records evidenced that staff took all practical steps to enable clients to make their own decisions. For clients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.

When clients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

During an assessment of the hospital overall

We assessed St Anne’s Community Services- Alcohol Services on 7 and 8 April 2026.

St Anne’s Community Services- Alcohol Services was registered with CQC in March 2011 to deliver the following regulated activity: Accommodation for persons who require treatment for substance misuse. The service had a Registered Manager at the time of the inspection.

The last inspection of this service was undertaken in September 2019 for which the service was rated good, with an outstanding in caring. We found:

  • The service provided safe care. The clinical premises where clients were seen were safe and clean.
  • The service had enough staff.
  • Staff assessed and managed risk well and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the clients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The staff teams had access to the full range of specialists required to meet the needs of clients under their care. Staff worked well together as a multidisciplinary team and relevant services outside the organisation.
  • Managers ensured that these staff received training, supervision and appraisal.
  • Staff treated clients with compassion and kindness and understood the individual needs of clients. They actively involved clients in decisions and care planning.
  • The service was easy to access. Staff planned and managed discharge well and had alternative pathways for people whose needs it could not meet.
  • The service was well led, and the governance processes ensured that its procedures ran smoothly.

At this inspection we did not identify any breaches of regulation.

At this inspection we assessed 1 assessment service group; Substance misuse services, where we assessed 34 quality statements.

The rating of the service has remained good.

3 September 2019

During a routine inspection

We rated St Anne’s Community Services – Alcohol Services as good because:

  • The service provided safe care. The clinical premises where clients were seen were safe and clean. The service had enough staff. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the clients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The teams had access to the full range of specialists required to meet the needs of clients under their care. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and relevant services outside the organisation.
  • Staff treated clients with compassion and kindness and understood the individual needs of clients. They actively involved clients in decisions and care planning.
  • The service was easy to access. Staff planned and managed discharge well and had alternative pathways for people whose needs it could not meet.
  • The service was well led, and the governance processes ensured that its procedures ran smoothly.

However:

  • Staff had not disposed of some clinical waste in line with the provider’s policy.
  • Clients and visitors did not have access to alarms to alert staff to their urgent need for support.
  • One bank nursing member of staff did not have access to the same levels of supervision as substantive staff. 

24 July 2017

During an inspection looking at part of the service

We do not currently rate independent standalone substance misuse services.

We found the following issues that the service provider needs to improve:

  • We found in one client record that staff had recognised potential safeguarding concerns and made an appropriate referral to the local authority. However, the registered manager had not submitted a notification to the Care Quality Commission which is a requirement of the Care Quality Commission’s (Registration) Regulations 2009.

We found the following areas of good practice:

  • St Anne’s Community Services – Alcohol Services had addressed all of the issues identified at the last inspection and was now meeting Regulations 12 and 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.
  • All clients had a risk assessment and risk management plan. Risk assessments were comprehensive and included all risks identified by the original referral. Staff undertook routine ongoing physical health monitoring of all clients admitted to both the detoxification service and the rehabilitation service. Physical health documentation was now stored together with care records. Staff undertook observations and assessments before administering pro re nata (as required) medication in line with the provider’s medication administration policy. The service was now regularly checking the defibrillator in line with the manufacturer’s guidance.
  • Systems were now in place to ensure that the registered manager had oversight of compliance rates for mandatory training, supervision and appraisals. The registered manager had implemented a weekly audit which monitored the quality and safety of the service provided. Care records were now of a consistent standard. In cases where the audit had identified issues in care records, there was evidence that the registered manager had taken appropriate action. Cleaning schedules were now being completed regularly.

4 April 2017

During an inspection looking at part of the service

We do not currently rate independent standalone substance misuse services.

We found the following issues that the service provider needs to improve:

  • At Anne’s Community Services – Alcohol Services had not addressed all the issues identified at the last inspection and still did not meet Regulations 12 and 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.
  • Risk assessments did not include all of the risks identified by the original referral. Clients with identified physical health risks did not have an appropriate risk assessment or plan to manage this risk.
  • The service’s process of monitoring the physical healthcare of clients put them at risk because the service missed changes in the physical health of clients whilst they were admitted to the service. This was because when a referrer had not identified a physical health need to the service, then the service would not undertake regular physical health monitoring.
  • Staff were not correctly and consistently ensuring that observations and assessments following the administration of ‘pro re nata’ (when required) medications to clients were completed and recorded as per the St Anne’s Alcohol Services medication administration policy
  • Managers did not have a system to monitor compliance rates for mandatory training, supervision and appraisals. Local audits had not identified areas of concern that we found with care records, risk assessments and cleaning schedules.

However, we also found the following areas of good practice:

  • The service had addressed several of the areas of concern identified in the previous inspection. This included sourcing child safeguarding training for staff, completing a risk assessment and plan for responding to emergencies, and introducing a system to monitor equipment to respond to emergencies. The service had explored and introduced alternative medication to support clients with physical health conditions through alcohol withdrawal.
  • The service had implemented several of the reported actions that the provider should undertake to improve identified in the previous inspection. This included purchasing a defibrillator and training staff in how to use it, introducing a formal programme of specialist substance misuse training for staff and introducing a statement of recovery produced in partnership with clients.

29 March 2016

During a routine inspection

We found the following issues that the service provider needs to improve:

  • St Anne’s Alcohol services were not assessing and managing risk effectively. Service risk assessments had not been completed on the use of mixed sex accommodation and client call alarms in the 18 bed residential rehabilitation unit. The medication and equipment required in an emergency, including a defibrillator, and the response time from the emergency services and distance to the nearest accident and emergency had not been risk assessed. Also, the service could not be sure that their equipment was in working order, for example, the staff communication radios. The system to record client risks was unclear and in the care records reviewed, risk assessments and risk management plans were either not present or incomplete. Not all staff were clear about reporting incidents where they felt intimidated as a risk. In addition, risk assessment was not included in the visit’s policy to safeguard children and vulnerable adults.

  • Patient physical observations and baseline observations were either not completed or not recorded, or discussed in the staff handover sessions. Similarly, assessments and observations for medication prescribed as the patient required it were either not completed or not documented in line with the services’ policy.

  • St Anne’s Alcohol Services had low compliance for some of its mandatory training, including moving and handling patients. This could impact the safety of the staff and the patients. Staff could not all identify child safeguarding risks and concerns, and staff had not received any child-safeguarding training to an appropriate level for their role. There was no formal programme of specialist substance misuse training for the administration of medication, including a schedule of competency assessments or supervised practice.

  • Care plans were not holistic and individually tailored to the client’s needs, and clients in the alcohol detoxification service did not get a named nurse on admission. None of the care plans had clear actions, and were not signed and dated by both the client and the staff member. Similarly, the alcohol detox could not be tailored to the client as there was no use of alternative medications.For example where a client had poor liver function. Clients in the alcohol services did not have a discharge plan in place on admission. Staff did not document decision specific mental capacity assessments in the client record where capacity had been a concern. Also, the services did not have any input from a dietician to ensure that they were meeting the nutritional requirements of the clients.

  • The mission, vision and values (core principles) were not embedded in St Anne’s Alcohol Services because staff were unclear what they were. Also, there was not a vision or statement of recovery specific to alcohol misuse for staff to embed in their practice, and for clients to work towards. The governance systems established had not operated effectively and were not embedded to assess, monitor and improve the quality and safety of the service provided. In addition, information required by the alcohol services management team to manage the services, for example for supervision, appraisal and training, was not held in one place, and was not accurate.

However, we also found the following areas of good practice:

  • Staff were caring and treated clients with kindness and respect. The staff had a strong person-centred approach. The service tried to meet the needs of all the clients who used the service and where they were unable to meet a client’s needs, they were transparent with the client and found them alternative service provision in partnership with the community, substance misuse service.

  • The psychological therapies, group-based interventions, medications and detox regimes used were evidence based and recommended by the National Institute for Health and Care Excellence. Staff received regular managerial and clinical supervision, and completed annual appraisals. The service completed a number of outcome tools to demonstrate that clients were making progress and meeting their goals. The alcohol services outcomes demonstrated that clients were making changes and leaving treatment having met their goals.

  • The environment at St Anne’s Alcohol Services was clean and well maintained, including the outside space. The services were responsive in their approach with clients. Clients had a pre-admission assessment within 10 days of being referred to the service and the usual wait time to access the alcohol services was 11 days from the pre-admission assessment to admission for both the alcohol detoxification service and the residential rehabilitation service. Clients had also been admitted immediately following the pre-admission assessment where this had been required. The doctor saw clients in the alcohol detoxification service immediately on admission. Also, St Anne’s Alcohol Services had been proactive in taking action to reduce their waits to enter the service and improve the service for the clients.

  • St Anne’s Alcohol Services were committed to improving the quality of treatment for clients, and the treatment outcomes, through their involvement in national research and projects. Staff, clients, relatives and carers felt able to feedback into the planning, delivery and development of the service. All staff told us that the service manager was approachable and supportive. They felt confident in being able to approach them with concerns without fear of victimisation. Lessons learned from incidents and complaints or compliments were also used to develop and improve the service.

3 January 2014

During an inspection looking at part of the service

When we visited St Anne's Community Alcohol Services in August 2013 we found that arrangements for the storage and recording of medicines were unsatisfactory. When we revisited the service we found the provider had taken action and improved arrangements for the storage of medicines and the standards of recording. We found people were protected against the risks associated with the use of medicines.

8 August 2013

During a routine inspection

We spoke with three people who used the service. They said they had been given information about their care and treatment. Their rehabilitation or detoxification programme had been explained to them and they had been given time to think before giving their consent. People said, 'They tell you exactly what will happen' and 'They discuss everything with us.'

People who used the service had individual care and treatment plans. The plans included a full assessment of their needs and an assessment of their motivation and expectations in terms of their use of alcohol. People had agreed individual goals or outcomes for their programme. People said the service had, 'Taught me ways of managing cravings' and 'Techniques on how to avoid alcohol.'

There were appropriate arrangements for obtaining, handling, safekeeping and dispensing of medicines. However, recording of the administration of medicines was not always accurate.

Staff were well supported and felt valued. They received appropriate professional development. They were encouraged and supported to obtain further relevant qualifications. Staff received regular individual and group supervision. One said they found the group supervision meetings particularly useful. They said staff discussed challenges they had dealt with and also shared good practice.

The provider regularly assessed the quality and performance of the service. Comments, concerns and complaints about the service were reviewed acted upon to improve the service.

27 July 2012

During a routine inspection

People we spoke with said they were very satisfied with the care and support they had received during their stay. One person discussed their treatment programme and what they had achieved at each stage. They said, 'The training programme has been beneficial and my confidence has escalated. I've had help in areas such as finding volunteer jobs. Everything is well co-ordinated. They have put the building blocks in place. It's nice to be back where I am.' Another person said, 'This is the best thing I've ever done. I feel 110% better and have more confidence. It's well organised, well run and everyone knows what they are doing.'

People who used the service told us they could express their views and were involved in making decisions about their lives. One person who used the service said, 'The programme is structured but works well, we get all the information so know what is happening next. Even when people are reluctant the staff are really good and help them.' Another person said, 'We get good support from staff and each other to talk things through and work out what is best.'

People told us that as they progressed through the treatment plan they built up their level of confidence and took more responsibility for their care in preparation for their discharge.

People who used the service told us there were enough staff working at the service and they had the right skills and experience. One person said, 'The staff provided support sessions about confidence building, alcohol awareness, managing my money and other areas I needed support with. They have helped me a lot.' Another person said, 'The staff are always available, helpful and have a good rapport with everyone.'

Staff told us people received good care and treatment. They said people received individual support with their treatment programme and effective systems were in place to make sure other agencies and professionals were involved when appropriate. They said every person had a clear treatment plan which was based on a structured programme and assessed throughout the rehabilitation period. Staff said they had received training to understand how to meet people's specialist needs.