Inspection on 14/03/06 for The Retreat

This inspection was carried out on 14th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Retreat 24/03/09

The Retreat 26/10/06

The Retreat 04/11/05

The Retreat 22/03/05

The Retreat 23/11/04

The Retreat 18/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 The Retreat 64 Hall Lane Walton On Naze Essex CO14 8HD Lead Inspector Neal Cranmer Unannounced Inspection 14th March 2006 09:30 The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 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 The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 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. The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Retreat Address 64 Hall Lane Walton On Naze Essex CO14 8HD 01255 675948 01255 861241 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) Reverend Graham Beresford Edwards Reverend Graham Beresford Edwards Care Home 4 Category(ies) of Learning disability (4) registration, with number of places The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed four persons) 4th November 2005 Date of last inspection Brief Description of the Service: The Retreat is owned and managed by Reverend Edwards and is the sister home of Peterhouse Residential Care Home. The home is a detached property offering a service to four people with a learning disability and is situated close to local amenities in the seaside town of Walton-on-Naze. The home provides a self-contained unit whereby service users are offered appropriate support. Single room accommodation is provided throughout; a number of communal areas are available within the home. The Retreat provides a pleasant garden area to the rear of the property. Transport is provided by the home. All service users have the opportunity to access day services provided at and by the sister home Peterhouse. The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day in March 2006, lasting 4.75 hours. The inspection process included discussion with one service user. The registered manager pointed out that the ladies living at the home are collectively referred to as residents, therefore the term “resident” has been used throughout the remainder of this report. Further discussion took place with the registered provider, the deputy manager and one member of staff. Tour of the premises included observation of toilet and bathing facilities, as well as communal living areas and gardens. During the course of the inspection a range of documentary evidence was sampled. Thirteen of the forty-three Standards were inspected, of which ten were met, the remaining three constituting minor shortfalls. What the service does well: What has improved since the last inspection? The one requirement identified from the last inspection was for the home to have a business plan; this requirement remains unmet, although some work has been undertaken. The registered manager was referred to a reference point for further advice. The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 Page 6 What they could do better: 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 Retreat DS0000017977.V262318.R02.S.doc Version 5.1 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 The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 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): 2. The needs assessment used by the home was seen to sufficiently identify residents’ needs and aspirations. EVIDENCE: The home has a pre-admission needs assessment which is used in conjunction with the referring agency’s assessment to formulate a view of the home’s ability to meet the resident’s needs. This information is then used as a basis to develop the resident’s plan of care. The pre-admission assessment presented was seen to cover all areas specified under National Minimum Standard 2. The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 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 and 9. Residents’ changing needs and personal goals are well reflected with their care plans. There was good evidence of risk assessment activity having been undertaken which was written with maximising independence in mind. EVIDENCE: Two residents’ care plans were sampled. Each contained details of the residents’ likes and dislikes, and each was seen to have been reviewed. The plans were laid out with details of important person contact details as follows: • • • Next of kin General practitioner Social worker The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 Page 10 The two care plans sampled contained evidence of risk assessment activity having been undertaken. The assessments identified the risks and the actions to be followed by staff to minimise the impact of the risk. At the end of each risk assessment was a hazard analysis sheet which summarised the following information: • • • • Nature of the hazard Level of risk Measures to be taken to manage the risk Probability factor The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 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): 12, 13 and 17. Residents’ needs are very complex, however evidence would suggest that residents are supported to take part in activities that are age and peer appropriate. Residents are supported to take an active part in community-based activities, primarily through their involvement with the local church. Menus seen evidenced that residents are provided with a healthy diet. Records were seen to be maintained of all meals consumed by residents. EVIDENCE: None of the residents residing at the home are in any form of paid or voluntary employment, although two attend a local Adult Education College, one twice weekly for everyday living skills and Makaton. The second resident also attends twice weekly for classes in an introduction to the college, where they are introduced to a taster of courses available and a second class on reading and writing. The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 Page 12 One service user presented evidence of a new project which they are currently working on entitled “Healthy Eating”. The service user indicated that this project has prompted them towards developing a healthier lifestyle. Discussion with the manager indicated that residents are involved in a range of community-based activities which included: • • • • • • • • • Involvement with the local church (one resident helps out at the church’s children’s club) Attendance of Gateway and Busby clubs Shopping trips Membership of the local library Going for meals out Visiting local public houses Visits to the local garden centres Aqua Springs Accessing a local sensory centre for people with sensory needs The home also has shared access to its own beach hut situated in a pleasant spot on the Essex coast. The home operates a three-weekly rotational menu which identifies breakfasts and teas. Meals at lunchtimes on Monday, Tuesday, Wednesday, Saturday and Sunday are taken at the home’s sister home Peterhouse; lunchtime meals are always cooked. The menus seen were varied and nutritious and the home maintains records of food consumed by residents. One resident fully prepares all their meals independently; the remaining residents participate in the preparation of sandwiches and help to wash up after meals. The deputy manager spoke of residents being involved in the purchasing of ingredients. One resident uses local shops to purchase many of the items they require which enables them to live semi-independently. The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20. Records seen evidenced that residents’ physical and emotional healthcare needs are well met. The needs of the residents are such that they are not able to manage their own medication. The home’s procedures were sampled and were deemed to be in order. EVIDENCE: All residents are registered with a local general practitioner and are seen by their optician twice yearly. Access to learning disability services is via referrals by the general practitioner. Records pertaining to residents’ healthcare needs were seen to be kept clearly and concisely. Medication at the home is dispensed directly from named containers. All staff receive in-house induction training on medication administration, as well as carrying out a distant learning pack. The home does not maintain any controlled medications. Unused medication is returned to pharmacy via the sister home’s medication returns process. The medication records sampled on the day of the inspection were found to be in order. The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 Page 14 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): No outcomes for this set of Standards were inspected on this occasion. EVIDENCE: The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 Page 15 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): No outcomes for this set of Standards were inspected on this occasion. EVIDENCE: The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 Page 16 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. Residents are supported by a team of staff who are competent and qualified to the appropriate standard. EVIDENCE: The home does not employ any trainees or carers under the age of eighteen, and staff left in a position of being in charge of the home are all aged over twenty one The home currently employs four members of staff, two of whom are qualified at NVQ Level 2, and one holds a Registered Nurse qualification. Observation of interactions between staff and residents evidenced staff to be: • • • Approachable and comfortable in the presence of residents Good listeners and communicators Interested, motivated and committed. The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 Page 17 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, 39, 42 and 43. Residents are supported in the home by a management team who have a significant amount of experience of working in the care sector and who are undertaking the necessary training commensurate with their roles. The home has in place a mechanism for reviewing and keeping under review the quality of their service provision. The registered person must ensure that the home’s safe working practices are adhered to. The registered person must ensure that a business plan is available for the home that is open to inspection by the CSCI. The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 Page 18 EVIDENCE: Both the registered manager and the deputy are qualified at NVQ Level 4 in management and are progressing well with their Level 4 in care. Both managers have significant previous experience of working in the care sector. Both undertake periodic training to enable them to remain up to date. The home has a quality assurance process in place by which to measure the quality of its service provision. The process included the dissemination of questionnaires to residents and their relatives as well as a number of internal audits which included: • • • • • • Six-monthly health and safety audits Staff turnover monitoring Staff sickness monitoring Medication monitoring audit Housekeeping monitoring record Record of policies reviewed The home’s safe working practices were sampled through the viewing of the following documentary evidence: • • • • • • • • • Fixed wiring Portable appliance testing Gas installation certificate- this was seen to be out of date, although the manager gave an assurance that this had been chased up Environmental Health Officer’s premises inspection report Record of weekly hot water monitoring checks Record of fire drills Record of fire alarm checks Monthly record of emergency lighting and doors Smoke alarm/bell test record The home’s business plan contained a reasonable amount of information in respect of the business, although further development could be made. The registered manager was referred to a reference contact point for further advice on developing a business plan. The home’s certificate of public liability insurance was seen and was current. Nothing seen gave any concern for the home’s ongoing financial viability. The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 Page 19 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 x 2 X 3 X X 2 2 Yes The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 Page 20 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 YA42 Regulation 12 (a) Requirement The registered person must ensure that safe working practices are complied with at the home. This relates specifically to the need to ensure that there is a current safety certificate in respect to the homes gas installation. The registered person must ensure that a business plan for the home is available for inspection that complies with regulatory requirements. The previous timescales of June 2005 and 31/01/06 were not met. Timescale for action 30/06/06 2. YA43 25 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA37 Good Practice Recommendations The registered person should achieve NVQ Level 4 in both care and management by the 31st December 2006. The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 The Retreat DS0000017977.V262318.R02.S.doc Version 5.1 Page 22 - 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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