Inspection on 17/11/05 for Queen`s Retreat

This inspection was carried out on 17th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Queen`s Retreat 01/05/07

Queen`s Retreat 07/03/06

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 Unannounced Inspection 17th November 2005 9.30am Queen`s Retreat DS0000060869.V266619.R01.S.doc Version 5.0 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.V266619.R01.S.doc Version 5.0 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.V266619.R01.S.doc Version 5.0 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.V266619.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 2005 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. The Home was previously registered as a children’s home but has recently successfully gone through the process of changing its category to Younger Adults. 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 Queen`s Retreat DS0000060869.V266619.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on two separate days, 17th & 22nd November. At the first unannounced visit the inspector met with the manager and examined documentation and records and undertook an inspection of the communal areas of the home. The second visit was arranged so that the inspector had the opportunity to meet the three service users who live at the home. The inspector is grateful to the staff for their open and co-operative approach and to the service users for their input into the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Queen`s Retreat DS0000060869.V266619.R01.S.doc Version 5.0 Page 6 The home needs to replace and refurbish the shower in the upstairs bathroom. 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. Queen`s Retreat DS0000060869.V266619.R01.S.doc Version 5.0 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.V266619.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 The home has a Statement of Purpose that reflects the service provided and also the ethos of care that is prevalent in the home. EVIDENCE: There have been no admissions to the home in the previous 12 months. The home has made the amendments to the Statement of Purpose that were required following the previous inspection. Queen`s Retreat DS0000060869.V266619.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8, & 9 The home has a system of care planning in place that is person centred and meets the needs of the service users. EVIDENCE: A sample of care plans were seen and these were detailed, up to date and being reviewed appropriately. Evidence was seen in recording of the involvement of service users in all aspects of the care planning. The views of service users are recorded regularly and examples were seen of staff acting upon the wishes and views of people. The home keeps a “home discussion book” in which details of service user views are recorded and also signed by them to show they are satisfied with what is being recorded about them. A service user stated that this system was “excellent…. because it helped them to learn and remember things”. Each service user has a number of personal files recording activities, events, medical needs, education and ongoing therapeutic interventions. The daily recording in individual files is written in a conversation style and after this information is shared with service users they sign to acknowledge they are in agreement with what has been written. Queen`s Retreat DS0000060869.V266619.R01.S.doc Version 5.0 Page 10 All archived files are stored and labelled in a clear and orderly way, which ensures that information is easy to access. All service users have had placement reviews with the home and local authority. The standard of recording within the home is excellent and evidence was seen in various entries of staff attempts to encourage and support independence and choice. Staff are able to demonstrate a high level of understanding of the needs of the service users and the philosophy of care employed in order to meet these needs. Queen`s Retreat DS0000060869.V266619.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 &17 The home supports the service users to develop individual lifestyles and plan for the future by encouraging the development of independence skills 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 care plans. Ensuring that service users have the opportunity and support to develop as they mature appears to be a fundamental aspect of the care provided. Service users all have weekly routines that they have been fully involved in developing. Evidence was seen that people were supported to make choices over changes to day time activities. These activities range from work experience settings, college attendance, key-working time in the home, therapeutic sessions and courses based at the organisations own education centre. Evidence was gained through records and discussion with service users that they are satisfied with the support they receive to take part in a range of activities and interests. These can be in the home, local community or further a field. Queen`s Retreat DS0000060869.V266619.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19&20 The training of staff, the recording and monitoring systems in place and the professional therapeutic input provided ensures personal and healthcare needs are correctly monitored and met. EVIDENCE: Healthcare needs are monitored and details of appointments and check ups are kept in the personal files. As at previous inspections the manager and care staff were able to demonstrate insight into the physical and emotional needs of service users. The home attempts to meet emotional and developmental needs, by ensuring that professional therapeutic input is provided, and that this is balanced with the provision and promotion of a homely and caring environment. The home’s records show detailed recording of the input provided and the recording in the personal files provided further evidence of the professional approach of the staff to meeting needs. Medication storage and administration were checked and found to be in order. Queen`s Retreat DS0000060869.V266619.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22&23 Service users are provided with a safe environment in which opinions are listened to and acted upon. Staff training, procedures and recording within the home reflect a professional and vigilant approach towards the area of protection. EVIDENCE: Service users stated they felt able to approach staff about any issues that concerned them. Staff are skilled at facilitating communication with one service user who has limited verbal communication. The home has a complaints procedure that includes a record book. There have been no complaints made within the last 12 months. The manager has completed training relating to Adults at Risk and all staff have also completed training in protection issues. Staff are able to demonstrate a good understanding of this aspect of care. The home does not employ any use of physical restraint. Evidence from liaison with the Commission and documentation of procedures followed within the home also contribute to demonstrate that the home exceeds the required the standard and is scored accordingly. Service user finances were not examined during this visit. Queen`s Retreat DS0000060869.V266619.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25, 26,27,28 & 30 Service users are provided with a homely and comfortable environment, which promotes their independence. EVIDENCE: The communal were inspected during this visit but it was evident from meeting with the service users that they were satisfied with their personal rooms. The shower in the bathroom needs to be replaced and the manager stated that this work is planned. 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.V266619.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34&35 The home has an experienced and motivated staff team that are able to meet the needs of the service users. EVIDENCE: Recording is detailed and consistent and demonstrates the staff teams understanding of the needs of the service users. One new staff member has commenced employment since the previous inspection and they are currently completing the homes induction procedure. Records show that the correct recruitment procedures have been followed. All the service users expressed very positive views about the support, advice and care they receive from the management and the whole staff team. Comments included “the staff help move me on and learn things”, “they are cheerful nice people”, “I would give them top marks, they always have time to listen and give advice”. Service users were also positive about the training and help they receive to develop independence skills such as cooking, managing finances and shopping for clothes. Staff and service users were observed interacting in a positive, respectful and appropriate manner. Queen`s Retreat DS0000060869.V266619.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39&42 The home is professionally managed with clear leadership and guidance for staff being provided. Record keeping is of a high standard that ensures that a clear link is maintained between documentation and practice. EVIDENCE: The manager has completed the Registered Managers Awards, the Certificate in Mental Health and also has a management qualification. The home appears to be efficiently run with all records up to date and a staff team that is supervised and motivated to work in a consistent and professional manner. The home has recently had an inspection from the Environmental Health Dept, and the recommendations put forward are being actioned by the manager. All fire safety checks have been completed and recorded and all staff and service users have received fire safety training. One staff member has the designated responsibility for being the homes “fire officer”. Queen`s Retreat DS0000060869.V266619.R01.S.doc Version 5.0 Page 17 All staff are up to date with the required statutory training. One staff member has completed a Health and Safety course and now has this designated responsibility for the home. Service users are provided with easy access to the management of the home to discuss any issues or concerns, and stated that they felt happy and comfortable to do this. Queen`s Retreat DS0000060869.V266619.R01.S.doc Version 5.0 Page 18 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X X Standard No 22 23 Score 3 4 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 3 3 4 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 3 X 3 LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 3 16 4 17 Standard No 31 32 33 34 35 36 Score x 4 x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Queen`s Retreat Score 4 4 3 x Standard No 37 38 39 40 41 42 43 Score 4 4 3 x x 3 x DS0000060869.V266619.R01.S.doc Version 5.0 Page 19 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 Standard YA27 Regulation 23(2)(b) Requirement The home must refurbish and repair the shower in the bathroom Timescale for action 28/02/06 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.V266619.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 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.V266619.R01.S.doc Version 5.0 Page 21 - 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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