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Inspection carried out on 21 November 2019

During an inspection looking at part of the service

We rated Shardale St Annes as good because:

  • The service provided safe care. The premises were safe and clean. The service had enough staff. Sickness and vacancies were low, which meant clients were cared for by a stable staff base who knew them well.
  • Staff assessed and managed risk well. All clients were assessed and only admitted if it was safe to do so. Harm minimisation was an integral part of the recovery programme.
  • All the records we looked at contained an up to date risk assessment and risk management plan that was reviewed by staff and clients on a regular basis. This had improved since we last inspected this service.
  • Staff followed good practice in safeguarding. They had training on how to recognise and report abuse, and they knew how to apply it. They understood how to protect clients from abuse and worked well with other agencies to do so. Clients also received information about safeguarding to help them recognise abuse.
  • The service had a good track record on safety and managed client safety incidents well. There was a clear process around reporting incidents, staff understood what they should report and how to do this. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
  • Staff completed comprehensive assessments with clients and worked with them to develop individual recovery plans.
  • The service was well led, and the governance processes ensured that its procedures ran smoothly.
  • Leaders had appropriate skills and experience. They had a good understanding of the service and were approachable for clients and staff. Staff knew and understood the provider’s vision and values and how to apply them in their everyday practice.
  • Staff felt respected, supported and valued. They told us their managers were supportive and caring. They felt able to raise concerns without fear of retribution. They received regular supervision, and training and appraisals were up to date.
  • Governance processes operated effectively. Performance and risks were managed well.
  • The provider collected and analysed data about outcomes and performance to monitor how well the service was performing. The service carried out regular audits to assess the quality of work. Managers reviewed the audits and fed back the results to the staff. This had improved since we last inspected this service.

Inspection carried out on 5 March 2019

During a routine inspection

We rated Shardale St Annes as requires improvement because:

  • Risks identified through assessments were not formulated into individual risk management plans that provided guidance for staff.
  • Recovery plans were limited in detail. They did not set out clearly what clients needed to do to complete the recovery programme or how they were progressing through the recovery programme.
  • Essential information about clients’ individual risk and progress through recovery was discussed and contained in handover notes but was not always transferred to clients’ individual records following discussions.
  • There was no date for review of therapeutic interventions.
  • The policy that provided guidance for staff working alone did not set out how the risks of working alone would be mitigated.
  • The provider’s monitoring systems had not identified the issues we found in care and treatment records.


  • The provider had developed a recovery programme based on seven core values and incorporating a disciplinary scaling process. The model focused on developing communication, resilience and personal responsibility within a supportive community environment.
  • There was an aftercare support programme that clients could access following completion of the recovery programme, to maintain their recovery and develop their peer support networks in the community.
  • Clients who were senior members of the community had roles of responsibility such as gatekeeper, safeguarder and community leader. The provider gave clients training and guidance in these roles so they could carry them out effectively.
  • Staff provided a range of care and treatment interventions suitable for the client group, delivered in line with national guidance and best practice.
  • The provider had a clear definition of recovery that all staff shared and understood. There was a clear sense of common purpose based on shared values. Staff were positive and proud about their work.
  • Managers had access to information about the performance of the service that supported their management role. Clients and carers could give feedback on the service they received.

Inspection carried out on 26 October 2016

During an inspection looking at part of the service

We do not currently rate independent standalone substance misuse services.

This was a focused inspection relating to issues identified at a previous inspection.

We issued a requirement notice following a comprehensive inspection in February 2016 relating to one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breach was in relation to regulation 5 (fit and proper persons: directors).

At this inspection, we assessed whether the service provider had made improvements to their arrangements for checking that the directors were fit and proper, which we identified in the requirement notice. We found that the provider had made the improvements and met the requirement notice.

At the last inspection in February 2016, we also found areas that the provider should take steps to improve. These were:

  • The provider should ensure that all staff are aware of and understand the principles of the duty of candour.
  • The provider should ensure that staff receive training so they understand the Mental Capacity Act.

At this inspection we were assured by looking at records and speaking with the staff on duty that the provider had taken steps to ensure that these areas had been addressed.

Inspection carried out on 29 February 2016

During a routine inspection

We do not currently rate independent standalone substance misuse services.

We found the following areas of good practice:

  • The environment was clean, well maintained, welcoming and comfortable.
  • There were sufficient staff to deliver the treatment programme.
  • Risk assessments were comprehensive and staff reviewed them regularly.
  • Clients were involved in decisions about their care and the service. There were agreed house rules and a behavioural code of conduct.
  • Staff demonstrated understanding of procedures for safeguarding clients from abuse. The managers acted as safeguarding leads.
  • Staff had completed core skills training to their required level.
  • Staff carried out assessments before clients were admitted to ensure that the service could meet the individuals’ needs.
  • Care plans were recovery focused. In the records we reviewed it was clear what clients’ goals were and how they would achieve them. The provider reviewed the care plans regularly throughout a client’s stay.
  • Care and treatment was underpinned by best practice. Clients had access to psychosocial therapies, group sessions and individual one to one sessions with a counsellor. Staff supported clients to engage with other recovery communities.

  • Staff worked with clients to help them develop the skills they needed to sustain their recovery and maintain their independence when they returned to the community.

  • Staff established therapeutic relationships with clients and involved them in their care.

  • Staff treated clients with respect and kindness and supported them throughout their stay.

  • All clients had full involvement with their treatment throughout their stay. They made decisions about their treatment during sessions with their keyworker.

  • Clients were involved in the running of the house. They were allocated trusted roles, such as community leaders, head of house, gatekeeper and safeguarder. Every month, the clients chose who should be allocated these roles, depending on the level of motivation they had shown in completing the programme.

  • There was a structured programme of care, therapy and activities. Discharge planning included an aftercare package to support clients following rehabilitation.
  • Staff had regular supervision and ongoing appraisals of their work performance from their manager, providing support and professional development so they were able to carry out their duties.
  • Staff we spoke with were highly motivated in their work and told us they felt supported by senior management. There was an open and transparent culture. Staff told us they felt comfortable raising any concerns or issues.

However, we also found the following issues that the service provider needs to improve:

  • There were no effective systems and processes to ensure that all directors were, and continued to be, fit, and that no appointments met any of the unfitness criteria set out in Schedule 4 of Regulation 5 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

  • There was a whistle blowing policy. Staff were aware of this and understood it. However, the policy did not cover the duty of candour and we were not assured through speaking with staff that they understood the principles of the duty of candour.