Shardale St Annes

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

We identified numerous issues in respect to the quality and cleanliness of the environment which did not contribute to a positive therapeutic environment for clients. It was not clear that maintenance issues were being identified and addressed in a timely manner or that processes were effective at ensuring any issues were being escalated as appropriate.

The service did not have an appropriate number of staff trained as fire marshals to ensure safe evacuation in the event of an emergency and staff were only trained in online first aid training at the time of the assessment.

The service had not submitted two statutory notifications to CQC in relation to incidents which would have been notifiable (incidents whereby registered providers must inform the CQC of their occurrence). It was not clear that the service had effective processes at monitoring, recording and reviewing incidents, or systems to ensure that the service was notifying external bodies as required.

However, the service had processes in place in respect of admissions and discharges to and from the service. The service had enough staff to support the number of clients and clients reported that they felt safe within the service.

The service was in breach of regulation with regards the premises and equipment within the service.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Managers at the service told us about two incidents that had occurred in the 12 months prior to the inspection. The service did not have a specific incident reporting system or form that staff would fill in when an incident had occurred. The registered manager stated they had written summaries of the incidents. There was therefore no evidence that incidents were effectively investigated, or that staff received feedback following incidents.

For both incidents, the service had contacted the local police force who had attended the service. The service had not submitted statutory notifications to CQC in relation to these incidents, despite them being notifiable incidents in line with Regulation 18 of the CQC (Registration) Regulations 2009. The service did not have a specific process to ensure that relevant agencies or organisations were submitted when an incident occurred.

It was, however, noted that the service generally had a low number of incidents and a small staff team.

Staff that we spoke to did not raise concerns about incidents within the service and felt confident that they could manage the service safely.

The service undertook assessments of potential admissions to the service. Clients would only be admitted to the service following a successful detoxification process with 5 days of abstinence being required prior to admission.

Where clients wished to exit their treatment early, staff made sure that the clients understood the decision they were making and asked them to sign declaration forms confirming that they understood the decision and had been informed of the relevant information by staff. We observed an example of where a client had wished to exit their treatment early and staff had recorded this as required and documented where they had contacted external parties as appropriate.

The service had some specific criteria which would prevent a potential client from being admitted to the service and managers were aware of what these were. The exclusion criteria was mostly around specific risk factors which could not be managed safely within the service.

The service had a policy for safeguarding clients from abuse. Managers explained that staff received training in safeguarding as part of their mandatory training. We requested data around the mandatory training compliance figures but this was unable to be provided due to unforeseen circumstances that impacted on the Registered Manager’s ability to fulfil the information requests. We could therefore not be fully assured that staff had completed this training as required.

The service utilised client roles as part of their model which included an allocated safeguarding client lead. The client lead could raise any concerns with staff.

Managers noted that the service set a culture that abuse would not be tolerated. Managers stated that any concerns would be handed over to the relevant social worker.

Managers gave an example where a potential safeguarding issue had been identified, and they had sought advice and guidance from the local authority.

The service did not have a specific safeguarding log with managers noting that it was very rare that the service made safeguarding referrals.

We reviewed 6 client records, all of which contained an up-to-date risk assessment and management plan.

Staff involved clients in care planning and risk assessment. Clients told us that they had been involved in their care planning. The client records that we reviewed were individual and personalised to the client and their identified needs.

Staff communicated with clients so that they understood their care and treatment, including finding ways to communicate with clients with communication difficulties.

Managers had the authority to refuse admission of any clients whose needs could not be safely met within the service.

Clients understood and agreed to the therapeutic interventions before they were admitted. Breaching the interventions incurred penalties that could eventually cumulate in discharge.

During the on-site inspection, we identified significant maintenance and decoration issues with the environment. We issued a letter of intent under our section 31 powers to the provider escalating our concerns and requesting an action plan as to what actions would be taken to address these concerns. The provider submitted a maintenance plan on the same day identifying the work that would be undertaken and giving timescales for completion; the majority of which were to be completed within two weeks.

On the day of the inspection, the service had 12 clients within the service, although the service had the capacity to have over 30 clients at a time. Many of the bedrooms had multiple beds within them, however, most of the clients in the service at the time of the inspection had their own bedroom due to the low occupancy rate.

In client bedrooms, there was wallpaper coming off the walls in places; staining on the walls and ceilings in areas; ripped and worn carpet; the lower section of sink appearing to be loose in one room; a hole in the wall of one bedroom behind the door. In one of the top floor bedrooms, there was a loft access point which had no cover on it and there was no indication of where the cover was.

Two of the client bedrooms were described by staff as being ‘out of bounds’ during the tour of the building. There was no signage on the doors to indicate this was the case and the bedrooms were not locked. One of these bedrooms had significant water staining on the ceiling and carpet, which we were told was the result of a leak. The other bedroom had damage to the ceiling and paper hanging down. It was not clear how long these bedrooms had been in this state of disrepair.

In two of the bedrooms, paper / cardboard had been placed over half of the light above a client bed.

We also reviewed the client bathrooms, toilets and shower rooms.

The light for one of the shower rooms was not working correctly, meaning the light in the room was dim. In the shower in this room, the grouting at the bottom of the shower and around the plug hole was black.

In a separate bathroom, there was significant damage to the bath which was taped up with grey tape. There was also staining to the ceiling and damage around the window frame.

In a further bathroom, there was a section of wall missing meaning there was exposed wiring and pipes. This toilet also had damage around the window frame. There was a shower which had black mould along the corners of the walls.

There was a toilet / shower room on the ground floor which had paint flaking off the walls and was damaged. The floor was stained and worn. The shower had a discoloured bathmat within it and black patches along the joins of the walls.

In the female area, there was a shower room where the shower controls appeared to be taped to the walls with a plastic bag cut up behind this. It was not clear as to why this was.

During our tour of the building, we also identified that the carpet leading up to the top floor was worn and frayed. The carpets generally throughout the building were old and not in a good condition. The carpet in the dining room was marked in numerous places.

In the quiet room, the sofa was frayed on the corners. There was some damage and marking to the walls in this room.

The outside laundry room was cluttered, messy and not in a good condition. There was also a door outside which was significantly worn and damaged along the bottom.

In one of the meeting rooms the chairs were worn, and one was damaged. The ceiling was stained, paper was coming loose and the window frame had gaps in it.

In the area around the back staff office, there was damage to the walls and areas which were worn. The carpet in the back staff office was significantly worn and frayed.

In the kitchen (in the basement area) there were two fire extinguishers which were not attached to the wall or in a stand, along with no signage around them.

The member of staff supporting the tour was unable to give specific answers as to how long areas had been damaged and was unsure when repairs were due to happen. They stated that any issues identified would be reported to management. Managers confirmed that the service did not have a maintenance log and that the Registered Manager generally took sole responsibility for reporting, arranging and having oversight of any required maintenance and the environment. Managers explained that staff would be expected to report any environmental issues to the managers directly or by recording this in the service’s daily communication book.

The Registered Manager had been limited in being on-site at the service for around 6 months prior to the assessment due to an incident not related to the service. They reported that this had impacted on their oversight and monitoring of the environment.

We reviewed some documentation relating to the environment and were not assured that the service had robust checks and appropriate arrangements to ensure that the service environment was always being managed safely. Following the on-site inspection, the Registered Manager confirmed via email that the service had undertaken PAT testing, an external fire risk assessment, the electric certificate had been completed, and all risk assessments were reviewed on the 21 May 2025. We requested copies of this documentation as part of our information requests. This was unable to be provided due to unforeseen circumstances that impacted on the Registered Manager’s ability to fulfil the information requests.

Following the first day of our on-site assessment on the 13 May 2025, we made a referral to the local fire and rescue service to share some of the concerns and issues we had observed in relation to the environment. The fire and rescue service undertook a fire safety visit to the service in July 2025 where they identified a number of fire safety issues that the provider was required to address and was given specific timescales in which actions were expected to take.

The service had a small staff team which comprised of 6 staff in total. This included the registered manager, the trainee registered manager and 4 unit assistants. The registered manager noted that, as occupancy increased, the plan would be to recruit further staff.

Staff and clients that we spoke to did not raise staffing levels as an issue or say that they felt there were not enough staff to support the care and treatment being delivered.

There was one member of staff on duty each night and this was managed on a rota basis.

The registered manager was the identified fire marshal however it was not clear what would happen if they were not present and who would take responsibility if a fire should occur in this situation.

If a medical emergency occurred, staff would contact local emergency services or clients would be supported in attending the accident and emergency department, although this would often be done with peer support rather than staff support.

Managers stated that staff received on-line first aid training and that the Registered Manager was the identified first aid trained member of staff. Managers noted that there was guidance available for staff in the service for certain medical situations, such as if a client was having a fit. We were not fully assured about the robustness of these procedures and staff’s confidence in following these in an emergency situation, particularly with only having received on-line first aid training. Managers noted that 4 staff had been booked on a 3-day face-to-face first aid course.

Staff had paper copies of mandatory training records within their staff folders. The service did not have a central record of all completed training dates or when training was due to be re-done. At the time of the assessment, we were informed that staff were expected to complete 6 mandatory training courses although the registered manager was exploring increasing this to 10 courses.

When reviewing staff folders, we were not able to clearly identify when mandatory training had been completed or if the records within the folders were up to date. We had requested data around the mandatory training compliance figures but this was unable to be provided due to unforeseen circumstances that impacted on the Registered Manager’s ability to fulfil the information requests. We could therefore not be fully assured that staff had completed this training as required.

The service used paper staff files only and these had not been kept in an orderly or structured manner. It was therefore difficult to understand where staff had completed or were overdue in respect of certain activities and tasks. It was not clear how managers had appropriate oversight or assurance of these folders or staff in general, as there were no clear processes for auditing these folders or providing assurance.

The environment was not being properly maintained at the time of the inspection and was not always clean. During our tour of the unit, we saw examples in client bedrooms of torn wallpaper and patches of staining.

The carpets throughout the unit were old, stained, worn and torn in places. This did not contribute to a positive therapeutic environment and could cause issues in terms of appropriately managing infection prevention and control.

Some of the furniture in the unit was torn in places or worn. This meant that the furniture would not be able to be cleaned appropriately as required and meant that infection prevention and control would be impacted.

Staff and clients told us that the cleaning timetable was done by the head of house who would then check that the cleaning had been completed. We were informed that the service undertook a deep clean twice a week.

No medicines were prescribed at the service. All medicines stored on-site were prescribed externally. Clients’ medicines were considered at the pre-admission assessment and prescribing of necessary medicines continued with a local GP.

Staff followed good practice in managing medicines. There was a policy that provided guidance for staff.

Clients’ medicines were stored in a locked cupboard, and they self-administered their medicines under staff supervision. Once medicines were observed to have been taken, staff recorded this, and they monitored compliance.

The service had a fridge in the staff office which was being used to store any unopened medication. The medication stated it only required refrigeration once it was opened. The fridge was not a medication fridge, and staff were not monitoring or recording the fridge or the room temperatures. Whilst the medication was unopened, it was a concern that, should staff have opened it and placed it back in the fridge, it could have been stored in an unsafe condition.

The service had a mandatory training course for the safe administration of medication. We had requested data around the mandatory training compliance figures, but this was unable to be provided due to unforeseen circumstances that impacted on the Registered Manager’s ability to fulfil the information requests. We could therefore not be fully assured that staff had completed this training as required.