Inspection on 04/11/05 for The Retreat

This inspection was carried out on 4th November 2005.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Retreat 24/03/09

The Retreat 26/10/06

The Retreat 14/03/06

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 09:30 4 November 2005 th The Retreat DS0000017977.V254005.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 The Retreat DS0000017977.V254005.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. The Retreat DS0000017977.V254005.R01.S.doc Version 5.0 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.V254005.R01.S.doc Version 5.0 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) 22nd March 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.V254005.R01.S.doc Version 5.0 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 November 2005, lasting 4.00 hours. The inspection process included: discussion with one service user, the registered manager, deputy manager and one member of staff. Tour of the premises included observation of service users’ bedrooms, bathing and toilet facilities, as well as communal and garden areas. During the course of the inspection a range of documentary evidence was sampled, most of which was found to be in order. Fourteen of the forty-three standards were inspected, all of which were met, bar one, which was a minor shortfall. What the service does well: What has improved since the last inspection? What they could do better: The home’s business plan requires some further development to fully comply with regulatory requirements. The Retreat DS0000017977.V254005.R01.S.doc Version 5.0 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 Retreat DS0000017977.V254005.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 The Retreat DS0000017977.V254005.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): 3. Observation of service users and staff interacting would suggest that the home is able to evidence its capacity to meet the assessed needs of service users. EVIDENCE: Observation of service users and interactions seen with staff would suggest that the home is able to demonstrate its ability to meet the assessed needs of service users. Staff were witnessed communicating with service users effectively and in their preferred means of communication. One service user was seen to be supported in the use of Makaton. The home does not provide a service to people whose needs it is not able to meet. The Retreat DS0000017977.V254005.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): 7 and 10. Service users are supported to the best of their abilities to make decisions about their lives. Evidence would suggest that service users’ personal confidential information is handled appropriately. EVIDENCE: Service users residing at the home are unable to manage their own financial affairs. Service users’ monies are held corporately and paid to the home by cheque to cover their fees. This payment includes service users’ personal allowances. The home has a comprehensive policy on confidentiality, which the manager stated is discussed with all staff during induction and which is also built into staff contracts of employment. The manager also stated that confidentiality issues are also discussed during team meetings. Attached to the confidentiality policy was a draft of principles for the governing of the sharing of information with partner agencies. The Retreat DS0000017977.V254005.R01.S.doc Version 5.0 Page 10 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): 15 and 16. Service users are supported very well to maintain links with their families. Evidence would suggest that the home works hard to support service users to maximise their independence to the best of their individual abilities. EVIDENCE: Discussion with the manager indicated that service users are supported to maintain links with family. The home had recently supported one service user to visit a member of their family in the north of the country (this statement was further supported during discussion later in the day with the service user themselves). The home’s policy on the receiving of visitors is one of an open door. Staff also support service users to maintain links through the writing of letters. One service user residing at the home lives semi independently in a flatlet next door, although staff are available for support should it be required. Staff always knock on service users’ doors before entering. Service users were seen to have unrestricted access to all areas of the home. The Retreat DS0000017977.V254005.R01.S.doc Version 5.0 Page 11 Discussion with the manager indicated that service users are encouraged to participate in day to day activities within the home. One service user was observed being supported by a member of the care team to wash up, another was reported to be very conscientious about the laying of the tables. Staff were witnessed interacting with service users continually and not exclusively with each other. The Retreat DS0000017977.V254005.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): No standards for this section were inspected on this occasion. EVIDENCE: The Retreat DS0000017977.V254005.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 and 23. The home’s complaint and adult protection policies and procedures are comprehensive and robust. EVIDENCE: The home’s complaint procedure was clear and concise and included timescales for responding. At the time of the inspection no complaints had been received by either the home or the Commission for Social Care Inspection. The home has a policy on recognising and responding to abuse, as well as whistle blowing, both of which were robust. The home would follow the Essex County Council’s guidelines for the reporting of allegations of abuse. All staff have received training in adult protection either in-house or externally, and all staff have received copies of the Vulnerable Adults Guidelines. The Retreat DS0000017977.V254005.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, 26 and 27. Service users are supported in an environment that is homely, comfortable and safe. Service users’ bedrooms are laid out in such a way as to promote their independence and individuality. The home provides adequate toilet and bathing facilities. EVIDENCE: The home is fit for its stated purpose, being readily accessible to all service users, in keeping with the local community and is reasonably close to local amenities. Furnishings and fittings were of a reasonable quality and were domestic in nature. On the day of the inspection the home was clean, bright and tidy, and free from any unpleasant odours. The Retreat DS0000017977.V254005.R01.S.doc Version 5.0 Page 15 Service users’ bedrooms visited were equipped with the necessary furnishings to meet their individual needs, and as specified under National Minimum Standard 26. There was evidence of service users’ personal possessions. Curtains and floor coverings were seen to be of a good standard. The home was registered as a pre-existing service and as such continues to provide adequate toilet and bathing facilities as at 31st March 2002. The Retreat DS0000017977.V254005.R01.S.doc Version 5.0 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): 34 and 35. Evidence would suggest that the home’s recruitment practices are robust in terms of protecting service users. The home provides training relevant to the needs of the service user group. EVIDENCE: The staff file of the most recent employee employed was sampled and all the documentary evidence required under Regulation 19, Schedule 2 of the Care Homes Regulations was found to be in place. A member of staff had been employed on the basis of an affirmative POVA first check (Protection of Vulnerable Adults) confirmed by telephone from the umbrella body. The manager confirmed that the member of staff was working in a fully supervised capacity and that all of the other rigorous pre employment checks had been carried out. The member of staff in question was on duty at the time of the inspection and confirmed the fact that they were working in a fully supervised capacity. All staff are inducted to the home over a period of six weeks. Staff training is identified through the annual appraisal, and the following training was identified as having taken place since the previous inspection: The Retreat DS0000017977.V254005.R01.S.doc Version 5.0 Page 17 • • • Makaton (in-house) Process of appraisal (in-house) Medication training (in-house) All staff were reported to be up to date with all their mandatory training. The Retreat DS0000017977.V254005.R01.S.doc Version 5.0 Page 18 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 and 43. Both the registered manager and their deputy have many years of experience of working in a care setting and both are N.V.Q qualified in management. The home has the basics of a quality assurance process which requires further development to fully represent the views of all interested stakeholders. The home’s business plan requires further development to comply with regulatory requirements. EVIDENCE: The registered manager has many years’ experience of working in the care sector and is close to completing their N.V.Q Level 4 award in management. The home’s deputy manager has completed the award, and both the registered manager and the deputy are registered for the care award. The Retreat DS0000017977.V254005.R01.S.doc Version 5.0 Page 19 The home has a quality assurance process which is carried out annually. This included questionnaires to service users and staff. The process could be further enhanced by the development of questionnaires to relatives and other interested stakeholders. The home has a basic business plan for the service which requires further development to fully meet with regulatory requirements. The home’s public liability insurance was current and was displayed. The Retreat DS0000017977.V254005.R01.S.doc Version 5.0 Page 20 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 x x 3 x x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x 3 x x 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 3 x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Retreat Score x x x x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x x 2 DS0000017977.V254005.R01.S.doc Version 5.0 Page 21 Yes 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 YA43 Regulation 25 Requirement The registered person must ensure that a business plan for the home is available for inspection, that complies with regulatory requirements. The previous timescale set of June 2005 was not meet. Timescale for action 31/01/06 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 YA39 Good Practice Recommendations It is recommended that the quality assurance process be further enhanced by broadening the dissemination of its questionnaires to a wider range of interested stake holders. The registered person should achieve a N.V.Q Level 4 in both care and management by the 31st December 2005. 2 YA37 The Retreat DS0000017977.V254005.R01.S.doc Version 5.0 Page 22 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.V254005.R01.S.doc Version 5.0 Page 23 - 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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