This is the latest available inspection report for this service, carried out on 10th June 2010.
CQC found this care home to be providing an Adequate service.
The inspector found there to be outstanding requirements from the previous inspection
report. These are things the inspector asked to be changed, but found they had not done.
The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.
Random inspection report
Care homes for adults (18-65 years)
Name: Address: The Retreat, Quedgeley 116 Bristol Road Quedgeley Gloucester Glos GL2 4NA one star adequate service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Lynne Bennett Date: 1 0 0 6 2 0 1 0 Information about the care home
Name of care home: Address: The Retreat, Quedgeley 116 Bristol Road Quedgeley Gloucester Glos GL2 4NA 01452728296 Telephone number: Fax number: Email address: Provider web address: manager@retreatgloucester.co.uk Name of registered provider(s): Name of registered manager (if applicable) Mrs Lisa Alicia Kritina Garvie Mr William Anthony Watkins Jeffers Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mr Grant Marcus Taylor care home 14 Number of places (if applicable): Under 65 Over 65 1 learning disability Conditions of registration: Date of last inspection Brief description of the care home 13 1 4 0 1 2 0 1 0 The Retreat is a large detached property on the Bristol Road in Quedgeley providing accommodation and personal care for up to fourteen people with a learning disability. The home is staffed twenty-four hours a day and has waking staff at night as well as a member of staff sleeping in. People are accommodated in single rooms on ground and first floor levels, some with en-suite facilities others with hand wash basins or shower cubicle washing facilities. On the ground floor there are two lounge/dining rooms, a kitchen, communal toilet and bathroom. Laundry facilities are located in a conservatory
Care Homes for Adults (18-65 years) Page 2 of 9 Brief description of the care home room at the back of the house adjacent to the kitchen. Located to the rear of the property is a patio area with a table and seating and a substantial garden that is laid to lawn. The outdoor unused swimming pool area has been fenced off. There is a car park for several cars to the front and side of the property. The home is located close to a residential development with supermarket, post office, garage and out of town business park with several consumer stores, restaurants and take-aways. The fees range from 600 pounds upwards depending on the individuals assessed need. The fee is determined by whether the needs for care are high, medium or low. The fees do not include the cost of items such as newspapers, toiletries, magazines, chiropody and sundry items and there may be charges for some transport, outings trips and holidays. A copy of the Statement of Purpose is available from the office. Copies of our inspection reports are displayed in the entrance hall. Care Homes for Adults (18-65 years) Page 3 of 9 What we found:
This random inspection took place in June 2010 and included a visit to the home on 10th June. The registered manager was present throughout. He had completed an AQAA (Annual Quality Assurance Assessment) as part of the inspection, providing considerable information about the service and plans for further improvement. It also provided numerical information about the service (DataSet). We had received surveys from 10 people living in the home and 2 members of staff. We also had feedback from social and health care professionals. Since our last key inspection of the home in September 2009 we had completed a random inspection in January 2010 to follow up an improvement plan. Ongoing improvements with the service provided were noted during that visit and again at this visit. The inspection focused on the requirements issued at the last inspection, case tracking two people living at the home including their medication records, examining recruitment and selection documents for two new members of staff and notification and accident records. We were also shown around the communal areas of the home. Since our last visit work has continued on developing a person centred approach which is reflected in care planning and the way in which people are supported. The AQAA stated, we actively listen and consult our service users in all aspects of choice making and involve everybody in the decision making process. People shared their new care plans and other documents with us which they were keeping in their rooms. Information in their terms and conditions had been personalised to reflect the service they receive. This document made good use of photographs and pictures. Each person also had an up to date copy of the Statement of Purpose and Service User Guide. People had copies of their Care Delivery Plan which they had signed. Both plans had been produced in the last six months. The review date was identified for these in 6 months time. The registered manager said that staff would be receiving further guidance on key working. A key worker system was in place and the first key worker group meetings had been held in May. The records we examined were up to date, clear and person centred. They provided a holistic assessment of peoples needs and from this care plans for peoples physical, emotional, intellectual and social needs were developed. Plans identified peoples spiritual beliefs and how these may impact on the service they received. Care and support plans stated peoples preferences for the gender of staff supporting them with their care. They also provided individualised information about the support they required and how this should be delivered by staff. Peoples wishes, aspirations, likes and dislikes were noted and reflected in their care plans. Each had an About Me document which included a communication profile giving an overview of how staff should interpret their verbal and non verbal behaviour. A communication dictionary also re-inforced this profile. Plans were produced in accessible formats using photographs, pictures and symbols. People said they liked the new format. One person was observed taking these to their annual review. Where other documents needed to be read in conjunction with care plans these were clearly identified. These included risk assessments and proactive and reactive behaviour management plans. Risk assessments were in place for such areas as moving and handling issues, community support and use of transport. Each person also had an individual fire risk assessment. Staff had received training in the management of challenging behaviour and were keeping incident records. Physical intervention would only be used as a last resort and was not being used in the home, distraction and
Care Homes for Adults (18-65 years) Page 4 of 9 diversion strategies appeared to be effective. Some restrictions were in place for instance a key pad to the front door. The rationale for these was described in risk assessments as in their best interests to safeguard people from possible harm. Staff had completed training in the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DOLS). No applications had been made for a DOLS. Daily records were in place evidencing how people had spent their time, what they had eaten and any incidents or accidents. People were observed going out to Dentist appointments, planning a shopping or library trip and choosing how to spend time at home. People said they like going to day care facilities nearby and one person goes to a farm regularly. The said they enjoy going to social clubs, to pubs and staying in touch with their family. People had planned day trips for later in the year. Each person had a Health Action Plan in place and annual health checks were taking place. They had access to a range of health care professionals including the local CLDT (Community Learning Disability Team). Referrals were made promptly when the home had concerns about peoples wellbeing. One person described how their needs had changed due to an accident (of which we had been informed) and how the home had responded. They had moved to a downstairs room and were being referred to an Occupational Therapist. Comments from social and health care professionals were positive and they had no concerns about the service received by people. We inspected the systems for the administration of medication. The AQAA stated, all service users that have been assessed to have the capacity to control their own medication have to date chosen to remain with the present system. Staff confirmed they had completed training in the safe handling of medication and that the management team observed them in practice. Competency audits were planned to be put in place annually. Medication systems were also be audited each month. Medication administration records (MAR) were completed satisfactorily. Handwritten entries were countersigned. Stock levels were entered on the MAR. Liquids and creams were labeled with the date of opening and the registered manager confirmed that all unused medication was returned at the end of the month. Returns books confirmed this. The temperature of the cabinet was being monitored and recorded. Protocols for the use of as necessary medication was in place. Homely remedies were not being used. A signature list was in place for all staff administering medication. No controlled drugs are kept in the home. Some improvements have been made to the environment. Changes were made to the lounge and dining room after consultation with people living in the home. Each space now has a lounge and an additional dining area allowing people to choose where they wish to eat. Damage to the wall in the old dining room had been repaired and was to be painted. Curtains and bedding were being gradually replaced. Peoples rooms were clean and tidy reflecting their interests and lifestyles. Some people had keys to their rooms whilst others had chosen not to keep their keys. The home was clean and tidy at the time of our visit. Infection control procedures were in place and personal protective equipment provided for staff. People have access to a well maintained garden. Surveys from people living in the home said, the home is nice and clean, and I like my room. One person commented they would like some flowers in the home. We looked at records for two new members of staff. Each had completed an application form and where there were gaps in employment history they had been asked to provide
Care Homes for Adults (18-65 years) Page 5 of 9 further information to provide a full employment record. Two satisfactory references had been obtained prior to appointment with the reasons for leaving former employment provided. There was evidence that an ISA Adult First check had been obtained and we examined CRB (Criminal Records Bureau) checks which were in place prior to staff starting work. CRB checks were being kept separately from staff files. Proof of identity and a photograph were in place. Staff had completed an induction at the home. We examined a new induction folder providing a pen picture of each person. Staff then complete the Skills for Care Common Induction with an external provider. Staff then have the opportunity to proceed onto a NVQ in Health and Social Care. The registered manager shared with us the homes training matrix and said that training for new staff in mandatory topics had still to be arranged. He was also in the process of sourcing refresher training for existing staff in mandatory topics such as food hygiene, fire and first aid. Surveys from people living in the home stated, I like all the staff. One person indicated that they would like more new staff. The registered manager explained that he had sent surveys to people living in the home, their relatives and other people involved in their care as part of this years quality assurance process. This information along with audits already in place and the Regulation 26 reports would be evaluated and outcomes used to produce an improvement plan. We examined a recent Regulation 26 report which was very comprehensive and identified areas for improvement. The registered manager was working through this. Some documents we examined during our visit confirmed these were being implemented. What the care home does well: What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Adults (18-65 years) Page 6 of 9 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action 1 39 24 (1-3) The Registered Person must 31/12/2009 develop the homes quality assurance system by reviewing its performance and writing a quality assurance report to demonstrate continual improvement and development in the service. (Work is in progress to meet this requirement. Timescale of 31/3/08 and 30/09/09 not met) Care Homes for Adults (18-65 years) Page 7 of 9 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action 1 35 18 The registered person must make sure that staff have the skills, knowledge and competencies necessary to support people living in the home. This is to make sure that staff are fit and competent to fulfil their responsibilities. 30/09/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 1 6 A record should be put in place evidencing monitoring and evaluation of care plans, providing a summary of any changes or how people are meeting these identified needs. Care Homes for Adults (18-65 years) Page 8 of 9 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Adults (18-65 years) Page 9 of 9 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
