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Calderdale Retreat Requires improvement

The local authority has identified this service as suitable to care for people discharged from hospital with a positive coronavirus (COVID-19) test result. We have checked it meets the infection prevention and control standards we expect. Find out more about these checks

We are carrying out a review of quality at Calderdale Retreat. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 12 August 2021

About the service

Calderdale Retreat is a purpose-built residential care home providing personal and nursing care to older people and people living with dementia. The service can accommodate 81 people. At the time of inspection there were 45 people using the service.

People’s experience of using this service and what we found

Medicines were not always managed safely. We found this was a breach of regulation 12 (Safe care and treatment).

The systems and processes to monitor the quality of the service had not identified or addressed the issues found in relation to the management of medicines. People did not have accurate, up to date and complete records. We found this was a continued breach of regulation 17 (Good Governance).

We made a recommendation that the provider should seek feedback from staff about staffing levels throughout the home.

Relatives we spoke with were complementary about how staff had helped their family member to keep in contact with them. Staff were positive about working at Calderdale Retreat and felt supported by the management team.

There were systems and processes in place to safeguard people from the risk of abuse. The premises were maintained. Infection prevention and control process were in place to help minimise the risk and spread of infections.

For more details, please see the full report which is on the CQC website at

Rating at last inspection and update

The last rating for this service was requires improvement (published 14 April 2020). There was a breach in regulation 17 (Good Governance). This service remains rated requires improvement. This service has been rated either inadequate or requires improvement for the last six consecutive inspections.

At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

We carried out an unannounced inspection of this service on 20 April 2021 to follow up on a breach of legislation at the last inspection. The provider completed an action plan after the last inspection to show what they would do, and by when, to improve governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service remains requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Calderdale Retreat on our website at

You can see what action we have asked the provider to take at the end of this full report.


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified breaches in relation to medicines management and governance at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan for the provider to understand what they will do to improve the stand

Inspection areas


Requires improvement

Updated 12 August 2021

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 12 August 2021



Updated 12 August 2021


Requires improvement

Updated 12 August 2021



Updated 12 August 2021

The service was not well-led.

Details are in our well-Led findings below.