Calderdale Retreat

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.

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 www.cqc.org.uk

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 www.cqc.org.uk.

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

Enforcement

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 standards of quality and safety. 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The service had been identified for use by the Local Authority as a designated care setting. We concentrated our inspection on the unit designated to provide care for people discharged from hospital with a positive Covid-19 status. The unit provided single en-suite rooms for up to 12 people. There were eight people using the service at the time of the inspection.

The home was closed to non-essential visitors due to local lockdown restrictions. A COVID 19 safe visiting centre had been purchased which meant people could see visitors without them entering the home.

An additional member of staff had been employed to support people to keep in touch with family and friends through regular telephone and video calls.

Red, amber and green zoning was in place within the designated setting to identify the areas of highest risk of virus transmission. As people recovered, or were awaiting discharge they could choose to move to the green zone which allowed them access to additional facilities such as a Jacuzzi bath.

A treatment room had been developed which enabled healthcare professionals to see people, able to go to the room, in private without the health care professional having to walk through the home.

Initiatives were in place to support staff's health and welfare.

We were assured that this service met good infection prevention and control guidelines as a designated care setting.

Further information is in the detailed findings below.

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 32 people using the service.

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

Medicines management had improved. We made a recommendation for further improvements in relation to the management of homely remedies and medicines to be taken ‘as needed.’

People received personalised care and support, but this was not always evidenced in the care records. People were supported to take part in a variety of social activities.

Improvements had been made to the way risks to people’s safety and welfare were managed. People told us they felt the service was safe. Accidents and incidents were monitored, and lessons were learned when things went wrong. The premises were well maintained and clean.

Staffing had improved and staff were available to respond to people’s requests for help in a timely way. People told us staff now had time to sit and chat with them. Recruitment had improved; all the required checks were done before new staff started work. Training had improved; people told us they were confident staff understood how to meet their needs. Staff told us they felt supported in their roles.

People were supported to eat and drink a varied and balanced diet. People told us the food was good. The service worked with other agencies to ensure people’s health care needs were met.

Staff treated people with kindness and respect. People’s dignity was respected, and they were supported to make decisions about their care and support.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; however, the systems in the service did not always support this practice.

Improvements had been made to the leadership and management of the service. Improvements had been made to the way complaints were dealt with. Complaints were used to improve the service. There were systems in place to monitor the quality and safety of the services provided. Further improvements are needed to ensure people experience good outcomes.

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 inadequate (published 24 July 2019). There were multiple breaches of regulations and the service was placed in Special Measures. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures. The service remains in breach of one regulation.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

Enforcement

We have identified an ongoing breach in relation to good governance.

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 standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Calderdale Retreat is a purpose built residential care home providing personal and nursing care for 41 people aged 65 and over at the time of the inspection. The service can accommodate up to 81 people across three separate units, each of which has adapted facilities. Only two units were operational; one unit provided nursing care, the other provided care for people living with dementia. The other unit was closed.

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

People were not safe. Risks were not assessed and appropriately managed. When accidents and incidents had occurred, action was not always taken to keep people safe. Lessons were not learned when things went wrong. Medicines were not managed safely. There were not always enough staff to give people the care and support they needed, particularly on the unit for people living with dementia. The recruitment process was not always followed robustly. Complaints were not always dealt with appropriately.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. Staff received induction and training, however this did not always equip them with the skills needed to do their job. Some staff had received supervision, but others had not. People did not always receive the healthcare support they needed in a timely way.

People received a choice of food and drinks. The environment was clean, well maintained and furnished to a good standard. People and relatives said they liked the staff, although we found staff practices varied. Some staff were kind and caring, whereas others weren’t, and people’s privacy and dignity were not always maintained.

People’s care records did not fully reflect their needs. Activities were provided by the activity organiser who was praised by people and relatives.

The service was not well-led. Leadership was weak and inconsistent due to repeated management changes in 2019 which, combined with a high turnover of staff, had impacted negatively on the service. Staff, people and relatives told us communication about these changes was poor. The provider’s quality assurance systems were not effective in identifying and addressing issues. The service has a history of providing poor quality care; it has only been awarded ratings of requires improvement or inadequate.

Following this inspection we met with the provider to discuss our concerns.

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

Rating at last inspection

The last rating for this service was requires improvement (published 5 June 2018).

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to safe care and treatment, person-centred care, dignity and respect, staffing, recruitment, complaints and good 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 referred our concerns to the local safeguarding authority and asked the provider to send us evidence of improvements and action points. This was used when decisions were made about our regulatory response.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Following the last inspection, we met with the provider to confirm what they would do and by when to improve the key questions to at least good. At this inspection we found the provider had taken steps to address all of the breaches and significantly improved the quality of the service. We have made two recommendations in relation to ensuring procedures to evidence the robust recording of staff checks and for information about people’s consent to be more accurately recorded.

Calderdale Retreat is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The care home accommodates 81 people across three separate units, each of which have separate adapted facilities. One of the units specialises in providing care to people living with dementia, one of the units is for people who need nursing care and the other unit is for people who require residential care. At the time of the inspection there were 25 people living at Calderdale Retreat and the ground floor residential unit was unoccupied.

There was a registered manager who had been in post since January 2018. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The registered manager had made some significant changes since coming into post and had made real progress to improve the quality of care for people through a clear action plan and targeted approach. All areas of the service provision had improved and actions had been taken to ensure there were no breaches in the regulations.

People were happy and well cared for, with their needs met in a person-centred way. We saw examples where people's health and well being had significantly improved since our last inspection. People's nutritional needs were well met and there was a good understanding of individual risks to people throughout the service. Medicines were well managed and there was good clinical oversight of people's health needs.

Care records were being improved to fully reflect people's needs. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Systems to recruit and induct new staff were in place although staff checks needed to be evidenced more clearly. Staff had clear direction and they were supported, trained and motivated to carry out their work. Communication had improved throughout the home and staff understood their roles and responsibilities. There were supportive relationships between staff and people in the home and there was a happy atmosphere with kind, caring and respectful interaction.

There was a newly emerging culture of openness and transparency, with good channels of communication between staff at all levels, people who used the service, relatives, visitors and other professionals in support of people's care.

Staff were involved and included in the implementation of new processes and systems to drive improvement in the service and as such they felt valued and respected. The registered manager had an oversight of the strengths of the service and the areas to improve and actively sought feedback from people, relatives, staff and other professionals. There was good evidence of partnership working to secure and embed improvements.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Calderdale Retreat is a care home which provides residential, nursing and dementia care to people. The service is registered for up to 81 people. There were 31 people living at the home when we carried out this inspection. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The care home accommodates people across three separate units, each of which have separate facilities. One of the units specialises in providing care to people living with dementia.

The home had an acting manager in post who was in charge of the home until a new registered manager was appointed. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found continuing concerns in relation to the three key questions and therefore the service still was not providing safe, effective or well-led care and identified continued breaches in regulations. Although some minor improvements were evident, the key priorities for people's basic care needs to be met, had not been addressed sufficiently.

The management of risks to individuals was poor.

Care documentation was poorly or inaccurately completed and staff did not have sufficient access to key information about people's needs.

There was a lack of management oversight of risks, such as the analysis of accidents and incidents.

Staff lacked direction and clear leadership.

The Care Quality Commission is considering the appropriate regulatory response to resolve the problems we found. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The overall rating for this service is 'Inadequate' and the service remains in 'Special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

There was a registered manager named, but who was no longer in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider had enlisted the support of a care management company to oversee the running of the home and they were in the process of appointing a new manager.

There were no safe systems in place to ensure individual risks to people’s health and well-being were known and managed. People did not receive safe care and treatment and they were not protected from abuse and avoidable harm.

Staffing levels and deployment of staff did not ensure people’s care needs were met. Recruitment procedures were not robust to ensure those working with vulnerable adults were suitable to do so.

Staff did not know the fire procedures in the home or how to evacuate people in the event of an emergency.

Many staff had not received an induction or any training and supervision and they lacked the knowledge and skills of how to meet people’s needs.

Staff did not understand the impact of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS). People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible; there were no available policies and systems in the service to support staff practice.

People’s nutritional and hydration needs were not managed well.

Some staff interactions were kind and caring; other staff interactions were not so caring and people did not receive compassionate care. People’s dignity and privacy was not respected.

Care was not person-centred. Documentation relating to people’s care and support was not completed accurately or used to plan their care effectively and safely. People’s individual wishes were not respected and their basic personal care needs were not met. Many people remained in bed without good reason.

Complaints had not been managed well, although the new management team was taking steps to address this.

There was a serious lack of leadership and direction for staff, with no oversight of clinical risks or key issues for people’s care. Systems and processes for monitoring the quality of the provision were weak and there was no robust management of the service. At the time of the inspection there was a new management team installed and they had begun to produce action plans for improving all aspects of the service. However, it was too soon for us to assess the impact of this upon people’s care.

The overall rating for this service is ‘Inadequate’ and the service has therefore been placed in ‘Special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures

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.