Calderdale Retreat

Updated 23 June 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Two inspectors, a medicine inspector and an Expert by Experience carried out this inspection. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Calderdale Retreat is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Calderdale Retreat is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced. Inspection activity started on 6 April 2023 and ended on 21 April 2023. We visited the location’s service on 6,12 and 19 April 2023.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spent time with people in the communal areas observing the care and support provided by staff. We spoke with 27 people who used the service and four relatives about their experience of the care provided. We spoke with 10 staff including the nominated individual, the registered manager, the general manager, senior care workers and care workers. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also spoke with 2 visiting healthcare professionals.

We reviewed a range of records. This included 10 people's care records and 14 people's medicine records. We looked at 3 staff recruitment files. A variety of records relating to the management of the service were reviewed.

Updated 23 June 2023

About the service

Calderdale Retreat is a residential care home providing personal care to up to 89 people. The service provides support to older people some of whom are living with dementia. At the time of our inspection there were 50 people using the service. The care home accommodates people across three separate wings, each of which has separate adapted facilities.

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

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

Medicines records were not always completed accurately which meant we could not be assured they had been handled safely. People were at risk of harm as the provider had not always identified, assessed or mitigated risks.

Quality audits were not always effective in identifying or securing improvements. The provider had identified some issues and started to address these through their action plan. People’s care records were not always accurate and up to date.

There were enough staff to meet people’s needs. Recruitment processes were robust. People said they felt safe in the home and safeguarding incidents were recognised and reported. The environment was clean and well maintained. Infection prevention and control measures were implemented. However, some concerns were raised by 2 relatives about visiting arrangements during a recent COVID-19 outbreak.

People and relatives spoke positively about the staff and the care and support provided. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The registered manager took action during and after the inspection to address the issues we raised.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 12 August 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

At our last inspection we recommended the provider should seek feedback from staff about staffing levels throughout the home. At this inspection we found the provider had acted on this recommendation and made improvements.

The service remains rated requires improvement. This service has been rated inadequate or requires improvement for the last seven consecutive inspections.

Why we inspected

We carried out an unannounced focused inspection of this service on 17 and 23 May 2022. Breaches of legal requirements were found. We served a warning notice regarding medicines in relation to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.

This inspection was carried out to follow up on action we told the provider to take at the last inspection. This report only covers our findings in relation to the Key Questions Safe and Well-led.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has not changed and remains requires improvement based on the findings of 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 www.cqc.org.uk.

Enforcement

We have identified breaches in relation to safe care and treatment and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.