CQC report explained · a residential care home
What the CQC found at Dewsbury 1
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm, with suitable staffing, risk assessments and fire arrangements. Infection-control guidance had been misunderstood on the first day, and one medicine record was incomplete, but the manager took action and no harm was reported.
- Effective?
- Good
- People received support that promoted choice, independence, nutrition and access to healthcare. Mental-capacity assessments, best-interests decisions and current DoLS authorisations were in place.
- Caring?
- Good
- This question was not rated in this inspection.
- Responsive?
- Good
- This question was not rated in this inspection.
- Well-led?
- Good
- Inspectors found a stable, supportive staff team, regular communication with relatives and useful quality checks. The improvement plan had not been updated since March 2023, but it was updated immediately after the second inspection day.
What inspectors found, November 2023
St Anne's Community Services - Dewsbury 1: Rated Good; inspectors found person-centred care, with minor medicine and infection-control recording issues.
The home supports up to five adults with learning disabilities. Five people were living there during the inspection. Inspectors visited unannounced on 18 and 24 October 2023, spoke with people, relatives and staff, observed care, and checked care plans and management records.
The home was rated Good overall. Safe, effective and well-led were all rated Good. Inspectors found enough suitably checked staff, appropriate risk assessments, clean premises, medicines given as prescribed, and good support with food, healthcare, choices and independence.
There were some shortfalls. Staff had misunderstood infection-control guidance on the first day, and one medicine record had not been updated when a medicine changed to 'as and when required'. The manager acted on both issues during or immediately after the inspection. The Effective rating improved from Requires Improvement at the previous inspection, while Safe and Well-led stayed Good.
Personalised support
Staff knew people's preferences and supported them to make choices about daily life. Inspectors described the atmosphere as relaxed and family-like.
“The interactions between people and staff were entirely natural and gave the service a 'family feel'.” from the report
Choice and independence
People were supported to choose how they spent their time, take part in household tasks and access community activities.
“People were empowered have control of their daily living as staff gave them choices and where needed, supported them to make decisions.” from the report
Suitable staffing
There were enough staff to support people safely in the home and in the community. Recruitment checks had been completed before staff started work.
“There were sufficient numbers of safely recruited staff to meet people's needs.” from the report
Improved legal records
Records about mental capacity and best-interests decisions had improved since the previous inspection. Relatives and representatives were involved in these decisions.
“People had a range of mental capacity assessments and best interests decisions in their care records, which showed involvement with people's relatives and representatives.” from the report
Good healthcare support
Staff worked with several healthcare professionals and had health action plans for each person. Staff also understood signs that someone might be becoming unwell.
“Each person had their own health action plan which provided details about how their healthcare needs were being met.” from the report
Infection-control guidance
needs fixingOn the first inspection day, staff were not following infection-control guidance because it had been misunderstood. The manager acted straight away, and inspectors reported no harm.
“On day 1 of our inspection, infection control guidance had been misunderstood by staff as this was not being followed.” from the report
Medicine records
needs fixingA medication audit had not identified that one medicine had changed from regular use to use only when needed. The record was updated immediately and inspectors found medicines were being given as prescribed.
“The medication audit did not identify that 1 person had a specific medicine changed from regular to 'as and when required'.” from the report
Improvement plan updates
minorThe continuous improvement plan had not been updated since the end of March 2023, although the management team had continued making improvements. It was brought up to date immediately after the inspection.
“The continuous improvement plan had not been updated since the end of March 2023.” from the report
- 01How do you now make sure all staff understand and follow current infection-control guidance?
- 02What checks are now in place to ensure medicine changes are recorded promptly and correctly?
- 03How will you keep the continuous improvement plan up to date and show that actions are completed?
- 04How does the home support my relative's choices, independence and access to community activities?
- 05How are relatives involved in mental-capacity assessments and best-interests decisions?
This inspection rated Safe, Effective and Well-led; Caring and Responsive were not rated in the report, and ratings for questions not inspected may carry over from the previous inspection. This explanation was written from the published report of 15 November 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2017
Rated Good overall; inspectors found safe, caring and responsive support, but the service was not always effective at recording best-interest decisions.
This was an unannounced inspection on 22 November 2017. Inspectors observed support, spoke with three people, two relatives and staff, and checked care records, medicines, recruitment, training, incidents, maintenance and audits.
The home was rated Good overall. Safe, caring, responsive and well-led were all rated Good. Inspectors found enough staff, safe medicines systems, kind support, personalised care and activities that matched people's interests.
Effective was rated Requires Improvement. People's choices were usually respected, but some best-interest discussions had not been recorded. The home sent evidence after the inspection that some missing records had been completed. The previous governance problems had improved and the home now met the relevant requirements.
Safety and staffing
People and relatives said they felt safe. Inspectors found enough staff, individual risk plans, emergency arrangements and safe recruitment systems.
“Risk assessments were individual to people's needs and minimised risk whilst promoting people's independence.” from the report
Kind, respectful support
Staff knew people well and supported their dignity, privacy, communication needs and everyday choices.
“We observed staff speak to people gently or with appropriate humour and they were kind and compassionate.” from the report
Personalised care
Care plans described people's preferences and support needs. People were helped to take part in activities, outings and hobbies they enjoyed.
“We found care plans were person-centred and explained how people liked to be supported.” from the report
Improved management
The previous inspection found weaknesses in governance. Inspectors found that audits and management oversight had improved by this inspection.
“At this inspection we found improvements had been made.” from the report
Best-interest records
needs fixingSome best-interest discussions had not been recorded to show that representatives had been consulted. The manager said these would be recorded, and some records were completed shortly after the inspection.
“best interest discussions had not always been recorded” from the report
- 01How do you now record best-interest decisions when someone may lack capacity?
- 02How do you show that relatives or advocates have been consulted about those decisions?
- 03Which parts of the care and risk records are checked regularly, and how are any gaps put right?
- 04How will you make sure activities and community outings continue to match my relative's interests?
- 05How are medicines checked and audited, including 'as required' medicines?
This was an unannounced inspection covering all five CQC questions and the overall rating, including checks of care, records, staffing, medicines, premises and management systems. This explanation was written from the published report of 23 December 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Dewsbury 1
3 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- November 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2017Goodup from Requires improvementSafe: GoodEffective: Requires improvementWell-led: Good
- December 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 15 March 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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At least 100 live-in carers within about an hour of Kirklees
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 86 can care for a couple. 11 years' experience on average.
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“Primrose is a very kind and compassionate healthcare professional”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.