Inspection on 01/05/07 for Queen`s Retreat

This inspection was carried out on 1st May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Queen`s Retreat 07/03/06

Queen`s Retreat 17/11/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Queen`s Retreat 7 Russett Road Cheltenham Glos GL51 7LN Lead Inspector Mr Simon Massey Key Unannounced Inspection 1st May 2007 10:00 Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queen`s Retreat Address 7 Russett Road Cheltenham Glos GL51 7LN 01242 703100 01242 706080 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Chances Gloucestershire Community Child Care & Family Support Services Mrs Beverley Anne Morgan Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2006 Brief Description of the Service: Queens Retreat is an older style detached property, set in private grounds on the edge of Cheltenham. The house is part of the Chances organisation, which has other homes in Gloucestershire. The home offers individually tailored packages of care and education to adults with disabilities. There is a strong emphasis on helping residents achieve a level of independence. The home also provides and supports education packages, both from its own education facility through to college and work placements. The current fee range for the home begins at £1200 to £1600 per week. Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This inspection took place on 1st May 2007 and lasted for 7 hours. The Inspector met with the Registered Manager and also members of the staff team. The Registered Provider was also present for part of the visit. Records relating to care planning, staff recruitment and training, health and safety and medication were examined. An inspection of the premises was also carried out. The Inspector also met with and interviewed the three service users who live at the home. The Inspector is grateful for their help and input in completing this inspection of the service. What the service does well: What has improved since the last inspection? What they could do better: The home needs to ensure it is fully conversant with the required recruitment checks that must be completed before staff commence employment. Some minor changes are required to the administration and storage of medications to ensure that best practice guidelines are followed. Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose provides accurate and accessible information to service users and prospective admissions to the home. The admission procedure ensures that people’s needs and aspirations are assessed prior to prospective residents moving into the home EVIDENCE: The home has a Statement of Purpose and Service User Guide that is available in picture and symbol form and accurately reflects the service provided. The home has had no admissions and currently has no vacancies. All the present service users have lived at the home for a number of years. Comprehensive assessments are in place, and the home has an admissions policy in place, which complies with the regulations. Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Detailed care plans ensure that the service user’s needs are documented and guidance is available to staff. The home takes action to encourage service users to make choices and supports them to take appropriate risks. Increased independence is an objective for all service users that the home supports them to work towards. EVIDENCE: The home has a care planning system in place that covers the range of needs that individuals have. There is evidence that appropriate reviews are undertaken and that all staff and service users have an involvement in this process. The plans include sections such as “Making a Positive Contribution to the Home and Community” and “Personal Dignity and Respect”. There was evidence of regular detailed recording, which is done in the first person and then shared at some point with the service user concerned. Service Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 10 users were positive about their support plans and the role these play in providing the care and support required. Service users appeared well informed about the content of their plans and the relevance they had. One person said that he thought his plan was, “really good” and that it, “ helped staff to understand me and what help I need”. Risk assessments relating to independence were in place and these were reviewed at regular intervals. Developing independence skills and confidence are key aspects of all of the plans and all the service users saw this as an objective they were working towards. The home keeps a record of service user views on any issue to do with the running of the home called the “House Discussion” book. The service users do not have “house meetings” but have the opportunity for individual discussions about any aspect of the running of the home with the Manager or Provider. Service users said they were happy with this arrangement and the Manager stated that this has proved to be a more effective way of accurately getting peoples views and opinions. Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home supports the service users to develop individual lifestyles and plan for the future by encouraging the development of independence skills Service users appear confident about their right to make choices and decisions about their lives Service users are encouraged to eat healthily but their right to choose is respected by the staff team. EVIDENCE: Therapeutic input is provided for the service users, either from in-house staff with the appropriate training or, if required, from outside professionals. These approaches are all documented and are linked to plans and objectives contained in the care plans. Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 12 The home has a commitment to enabling people to develop their skills, including social, emotional, communication and independent living skills. People are supported to identify goals and to work to achieve them. All service users have a variety of activities and interests that they are supported to enjoy, both in the home and in the community. Some are done as a group and some individually. Recording showed regular activities taking place and the service users all expressed their satisfaction with this aspect of their support. Service users are supported to maintain appropriate relationships with families and friends, with advice and counselling being available. There was evidence that dignity and privacy is respected, with people being afforded privacy in their rooms and staff communicating and relating to service users in a respectful and appropriate manner. Service users spoke highly of the relationships they have with the staff team. People are involved in menu planning and shopping and all take part in meal preparation. People were very positive about the choice and quality of food that is prepared, and were also aware of the skills required to develop their independence in this area. Service users said they are encouraged to eat healthily but that they are also offered a choice or preference. Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health needs are closely monitored and appropriate professional input provided to meet the needs of the service users, and provide advice and guidance for the staff team. Medication administration and storage is adequate but some changes are required to ensure that best practice is followed. EVIDENCE: The care plans detail the personal care and support that is required. They also detail any personal wishes or preferences that people have in terms of how the care is delivered. The records show regular visits to health professionals for routine checks as well as for other issues. All staff undergo medication training before they are allowed to administer to service users. Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 14 The medication storage and administration was examined and found to be largely in order. There is a need to date all creams and ointments when they are opened to ensure they are not used past their shelf life. The home needs to be aware of the recommended times that these potions are effective for. The recording also refers to “controlled medication” which does in fact mean “prescribed” medication. This labelling is misleading and should be changed, as the home does have any “controlled medication” to administer. Whilst the room where medication is kept is locked, the key is generally left in the cabinet. This is unsafe practice and this key should be securely stored and the cabinet kept locked. Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provides a safe environment for service users in which they are respected and treated with dignity. The home has satisfactory arrangements and procedures in place for the protection of service users. EVIDENCE: Service users are aware of how to make a complaint or raise a concern about any aspect of the support and care provided in the home. Service users appear comfortable and confident with the care staff and management and explained how they can approach key workers, the Manager or the Provider, if they wish to discuss anything they are unhappy with. The home has a formal complaints procedure in place that is provided in picture and symbol formats. All staff have completed training in the area of Adult Protection, and the home is clear about its responsibility if a referral is required to the Local Authority as part of the Safeguarding procedures. The home has demonstrated that it is clear and transparent when discussing any issues with external bodies. No physical intervention or restraint is used in the home. Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a home that is well maintained and decorated throughout and provides a comfortable homely environment. Service users are supported and encouraged to personalise their living space and are involved in all decisions relating to redecoration of the home. Bathroom facilities are compromised by the length of time it is taking to complete the refurbishment and upgrade of the shower and bathroom flooring. EVIDENCE: The communal areas and bedrooms were inspected during this visit and it was evident the service users are satisfied with their bedrooms and that the communal areas meet their current needs. Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 17 None of the service users have lockable bedroom doors but the manager stated that this would be provided if requested. The shower in the bathroom has now been replaced but the flooring has yet to be completed and there was tripping hazard around the exit to the shower cubicle. The work on this room has been continuing for a considerable period and now needs to be completed. The home appeared clean and hygienic throughout. The areas inspected and the exterior of the property was reasonably maintained and tidy. The home has no need for specialist equipment or adaptations. Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user needs are met by a qualified and motivated staff team who relate well to the service users. Some shortfalls in the recruitment procedures could result in the protection of service users being compromised. EVIDENCE: Service users were positive about the quality of staff that provides the support and care. People stated that the staff treated them well and with respect, and many positive interactions were observed during this inspection. Recording and conversations with staff showed there is a good understanding of their roles and the needs of the service users. Staff are also able to demonstrate a good understanding of the values, aims and objectives of the care provided. Sufficient staffing is provided in the evenings and weekends to support individual and group activities, with additional staff being available through agreement if a need is identified. Staff and service users considered the Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 19 current staffing levels to be sufficient. Staff consider themselves supported in their roles and are able to approach management for advice or support. All new staff complete an induction period and are then expected to complete a foundation course before undertaking NVQ training. The majority of staff are now trained to at least NVQ level 3. Some shortfalls were identified in the recruitment procedures. There is a need to ensure that all checks are completed before staff commence employment, including references from their last employment in care and a Pova First check, when there is a delay in obtaining some information. If an urgent need arises to start new staff before all checks are completed, this should be done in agreement with the regulator, and the situation should be risk assessed and recorded. All references should be verified and where possible provided on headed paper. The shortfalls were as a result of misunderstanding of procedures and the Manager undertook to address these issues. Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users benefit from a home that is well managed and organised and committed to providing high quality care and support. Systems are in place that help to monitor and improve the quality of the service. There are a range of measures in operation that help to protect service users’ health and safety. EVIDENCE: The Registered Manger is qualified and experienced and is able to demonstrate a good understanding of their role and responsibilities. They have additional Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 21 experience in other care settings and appear motivated towards providing a high standard of care and support for the service users and leadership for the staff team. Staff and service users both stated that the management of the home was approachable and supportive. With the exception of the omissions mentioned elsewhere in the report, all administration and recording is completed to a high standard and the home is well-organised and efficient, whist retaining a homely and friendly atmosphere. All records were securely stored but easily accessible, and all files seen were well organised The manager has a role in monitoring practice and ensuring that the home maintains a safe environment. The home has a thorough system for ensuring health and safety is maintained and that all checks are completed and recorded. All staff are up to date with the required statutory training. The home has regular visits from the Provider, who has an involvement in the care of the service users. The home has quality assurance systems in place to monitor practice and to identify any improvements that can be made. Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 4 X 3 X X 3 x Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA24 YA34 Regulation 23(2)(b) 19(4) Requirement The home must complete the refurbishment of the bathroom The home must ensure that all required checks are completed on new staff before they commence employment The home must ensure that all medical creams and ointments are labelled with the date of opening The home must ensure that the key to the medicine cabinet is kept securely Timescale for action 30/05/07 30/05/07 3 YA20 13(2) 30/05/07 3 YA20 13(2) 30/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Queen`s Retreat DS0000060869.V334617.R01.S.doc Version 5.2 Page 25 - 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. 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