Inspection on 26/10/06 for The Retreat

This inspection was carried out on 26th October 2006.

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 1 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 14/03/06

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 26th October 2006 09:30 The Retreat DS0000017977.V302284.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 The Retreat DS0000017977.V302284.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. The Retreat DS0000017977.V302284.R01.S.doc Version 5.2 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.V302284.R01.S.doc Version 5.2 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) 14th March 2006 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 fees for the home are between £718.80-£793.01 per week, there are no additional charges made by the home, these scale of charges were provided in the Pre-Inspection Questionnaire provided to the Commission on the 23rd October 2006. The Retreat DS0000017977.V302284.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place over one day in October 2006, lasting 5.00 hours. The registered manager pointed out that people residing at the home prefer collectively to be referred to as residents, therefore this term has been used throughout the body of the report. The inspection process included discussion with one resident, the registered manager and one member of the care team. Tour of the premises included observation of service users bedrooms, toilet and bathing facilities, as well as communal areas. During the course of the inspection a range of documentary evidence was sampled. Twenty-two of the forty-three standards were inspected, of which twenty were met, and one was partially met, and one resulted in a recommendation being made. What the service does well: What has improved since the last inspection? The home now has a business plan for the home that is available for inspection and that now meets with regulatory requirements. All relevant safety certificates relating to the safe running and management of the home are now in place. The Retreat DS0000017977.V302284.R01.S.doc Version 5.2 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 summary of this inspection report can be made available in other formats on request. The Retreat DS0000017977.V302284.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 The Retreat DS0000017977.V302284.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): 2. Quality in this outcome area is (Good) This judgement has been made using available evidence including a visit to this service. Residents can expect that their needs will be assessed prior to a service being offered. EVIDENCE: The home has not admitted any new residents for a number of years, however a Performa for admitting future residents was provided, which covered the following areas: • Medical history • Sight and hearing • Current physical health status • Dental history • Means of communication • Relationships with others • Details of the referring agency. Discussion with the registered manager indicated that this initial assessment would then be used to formulate the basis for the service users individual plan of care. The Retreat DS0000017977.V302284.R01.S.doc Version 5.2 Page 9 The Retreat DS0000017977.V302284.R01.S.doc Version 5.2 Page 10 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 (Good) This judgement has been made using available evidence including a visit to this service. Residents can expect that their assessed and changing needs will be reflected in their individual plans of care. Residents are supported to make decisions about their everyday lives with assistance. Residents can expect to be supported to take risks as part of developing an independent lifestyle. EVIDENCE: Three service users care plans were sampled, each was seen to have a plan of care, which was kept under review, daily records were linked to the identified objectives in the care plan with guidance to staff on how to support service users toward meeting the identified objectives. The Retreat DS0000017977.V302284.R01.S.doc Version 5.2 Page 11 Observational evidence was seen of residents being supported to make limited choices; one resident was seen being supported to make a choice of a book that they wished to look at. Daily records showed evidence of residents being supported to make choices about meals. None of the residents residing at the home are able to manage their own financial affairs, although the majority have their own bank accounts; the provider is in the process of pursuing this for the resident who currently does not have their own account. The provider is signatory for two of the residents, money held in the home on behalf of residents is maintained on behalf of residents and released as required. Records sampled on the day were found to be in order. Evidence was seen of risk assessments having been undertaken, guidance to staff on actions to be followed to minimise the impact of the identified risk presenting was good. The Retreat DS0000017977.V302284.R01.S.doc Version 5.2 Page 12 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, 15, 16 & 17. Quality in this outcome area is (Good) This judgement has been made using available evidence including a visit to this service. Residents can expect to be supported to take part in activities that are age and peer appropriate. Residents are supported to take part in their local communities. Service can expect to be supported to maintain links with their families and friends. The daily routines of the home respect the rights and responsibilities of service users. Residents can expect to be provided with a healthy and wholesome diet. EVIDENCE: The Retreat DS0000017977.V302284.R01.S.doc Version 5.2 Page 13 None of the residents residing in the home have any paid or voluntary employment, although two attend a local Adult Education College, where they are involved in a variety of classes. Discussion with the registered manager, as well as sampling of records indicated that residents are involved in a range of community-based activities, which included: • Involvement with local church • Trips out shopping • Use of the local library • Meals out • Trips to local public houses • Trips out to local garden centres • Visits to local spa centres • Accessing a specialist service for people with sensory needs. The home during summer months also has shared access to a beach hut situated in a pleasant spot on the Essex coast. The home has an open door policy on the receiving of visitors, one resident spoke of their mother visiting the home the next day, to celebrate their birthday. The registered manager spoke of supporting resident’s relatives to maintain contact by providing transport to facilitate visits. Residents were witnessed being supported by staff, using their preferred terms of address, the interactions seen and heard were positive and respectful, residents were seen to have unrestricted access to all areas of the home. The home operates a three-weekly rotational menu, which were seen to be varied and nutritious, the home maintains a record of meal consumed by residents. One resident continues to prepare all of their meals independently; the remaining residents participate in the preparation of sandwiches and snacks, and assist with tidying up following meals. Residents are involved in the purchasing of food stocks. On the day of the inspection residents were witnessed taking part in the preparation of the lunchtime meal. The Retreat DS0000017977.V302284.R01.S.doc Version 5.2 Page 14 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. Residents can expect to receive personal support in a way that is appropriate to their needs. Residents can expect that their physical and emotional healthcare need will be well met. Residents are protected by the home’s practice on the administration of medicines. EVIDENCE: One of the three residents residing at the home is for the most part independent in terms of meeting their personal needs. The remaining residents are supported by an all female support team, the home operates a key worker system and from discussion with the registered manager, it was evident that one resident was able to choose who they wished to have as their key worker. The Retreat DS0000017977.V302284.R01.S.doc Version 5.2 Page 15 It was evident that the other residents had had the process explained to them. Residents are free to choose when they wish to go to bed, records sampled showed that service users generally retired to bed between 9.00 and 10.00pm. All residents are registered with a General Practitioner, and are seen by their optician twice yearly. Access to learning disability services are now made direct. Records relating to service users healthcare needs are kept clearly and concisely. Medication at the home is dispensed directly from named containers. All staff have received in-house training on the administration of medicines, which has been supplemented further by the completion of distant learning packs. The home does not maintain any controlled drugs. Unused medicines are returned to pharmacy via the home’s sister home’s returns process. Medication records sampled on the day of the inspection were seen to be in order. The Retreat DS0000017977.V302284.R01.S.doc Version 5.2 Page 16 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. Residents can expect that their views will be listened to and acted upon, and that the home’s practice protects service users from the risk of harm or abuse. EVIDENCE: Since the previous inspection to the home no Complaints or Adult Protection referrals have been made in respect of the home. The home’s policies and procedures for managing complaints and adult protection matters are robust. All care staff have received training in Adult Protection, or are scheduled to attend in the very near future. The home maintains a log for the recording of complaints received The Retreat DS0000017977.V302284.R01.S.doc Version 5.2 Page 17 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 (Adequate) This judgement has been made using available evidence including a visit to this service. The environment at the home is tired and worn, and lacks a feeling and appearance of homeliness. Despite being tired and worn the home was maintained in a clean state. EVIDENCE: Tour of the premises showed the home to be generally fit for its stated purpose, being safe and reasonably well maintained, although the home was comfortable, the décor and furnishings in the home are domestic in nature, however both are becoming very tired looking, and it was noted that their was an absence of homeliness, for example little evidence of pictures, or ornaments. The Retreat DS0000017977.V302284.R01.S.doc Version 5.2 Page 18 It was noted that there was no evidence of any unpleasant odours about the home. The home is situated reasonably close to local amenities, and is on a local bus route, the premises are in keeping with the local community. The home is accessible to all residents. The Retreat DS0000017977.V302284.R01.S.doc Version 5.2 Page 19 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) Residents can expect to be supported by a team of staff who are competent and well trained. This judgement has been made using available evidence including a visit to this service. Residents can expect to be protected by the home’s practice on staff recruitment. Residents can expect that their individual and joint needs will be met by staff that are well trained. EVIDENCE: Three staff files were sampled in relation to the home’s recruitment practice, all of the records required by regulation were found to be in order, all three files contained copies of statements of terms and conditions, references, and necessary police checks. Evidence indicated that the home’s recruitment practice is sufficiently robust to ensure that residents are protected from the risk of harm and or abuse. The Retreat DS0000017977.V302284.R01.S.doc Version 5.2 Page 20 All staff receive structured induction to the home over a six week period, the training and development policy showed that an informal review takes place after six months, this is then followed up by an annual appraisal, these are used to review performance, set future objectives and assess training needs. Staff are formally supervised on a bi-monthly basis, and team meetings are held every six to eight weekly. Training undertaken since the previous inspection included: • Foundation certificate in food hygiene • Adult protection training • Moving and handling • Safe handling of medicines • Certificate in first aid. Staff spoken with during the course of the inspection indicated that access to staff training is generally good. The Retreat DS0000017977.V302284.R01.S.doc Version 5.2 Page 21 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 & 43. Quality in this outcome area is (Good) This judgement has been made using available evidence including a visit to this service. Residents can expect to be supported through the ethos of a home that is well run. Residents can expect that their views will be sought, as a part of the quality review process of the home. Residents can expect that the home’s practice will protect and promote their health and safety. The home is financially viable, and is managed competently. EVIDENCE: The Retreat DS0000017977.V302284.R01.S.doc Version 5.2 Page 22 The registered manager is qualified at N.V.Q level four in management, and is progressing well with their award in care. The manager has significant previous experience of working in the care sector, and undertakes periodic training to enable them to remain up to date. A quality assurance report for the home was submitted based upon questionnaires from residents and staff, where less positive responses were included, a response was provided by the provider, the report was seen to include copies of audits, action plans, and copies of the previous CSCI inspection reports. The home’s safe working practices were sampled through the viewing of the following safety records: • Portable appliance test records • Fixed wiring • Gas installation certificate • Record of hot water • Record of fire drills • Record of fire alarm checks • Monthly record of emergency lighting • Smoke alarm/bell test record • Control of substances Hazardous to Health Assessments. The home now has a Business Plan open to inspection by the CSCI, current insurance liability was seen to be in place, nothing seen suggested concern for the home’s on-going financial viability, lines of accountability within the home were clear. The Retreat DS0000017977.V302284.R01.S.doc Version 5.2 Page 23 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 2 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 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 X 3 X X 3 3 The Retreat DS0000017977.V302284.R01.S.doc Version 5.2 Page 24 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 YA24 Regulation 23 (b&d) Requirement The registered person must ensure that the home is kept in a good state of repair internally, and ensure that all parts of the home are kept reasonably decorated. Timescale for action 31/12/06 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. 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