This inspection was carried out on 14th January 2010.
CQC found this care home to be providing an Adequate service.
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.
Random inspection report
Care homes for adults (18-65 years)
Name: Address: The Retreat, Quedgeley 116 Bristol Road Quedgeley Gloucester Glos GL2 4NA one star adequate service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Lynne Bennett Date: 1 4 0 1 2 0 1 0 Information about the care home
Name of care home: Address: The Retreat, Quedgeley 116 Bristol Road Quedgeley Gloucester Glos GL2 4NA 01452728296 Telephone number: Fax number: Email address: Provider web address: manager@retreatgloucester.co.uk Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mr Grant Marcus Taylor care home 14 Number of places (if applicable): Under 65 Over 65 1 learning disability Conditions of registration: Date of last inspection Brief description of the care home 13 The Retreat is a large detached property on the Bristol Road in Quedgeley providing accommodation and personal care for up to fourteen people with a learning disability. The home is staffed twenty-four hours a day and has waking staff at night as well as a member of staff sleeping in. People are accommodated in single rooms on ground and first floor levels, some with en-suite facilities others with hand wash basins or shower cubicle washing facilities. On the ground floor there is a lounge, separate dining room, kitchen, communal toilet and bathroom. Laundry facilities are located in a conservatory room at the back of the house adjacent to the kitchen. Located to the rear of the property is a patio area with a table and seating and a substantial garden that is laid to lawn. The outdoor unused swimming pool area has been fenced off. There is a car park for several cars to the front and side of the property. The home is located close to a
Care Homes for Adults (18-65 years) Page 2 of 10 Brief description of the care home residential development with supermarket, post office, garage and out of town business park with several consumer stores and restaurants take-aways. The home is on a main bus route that can take people into Gloucester city centre, which is approximately three miles away. The fees range from GBP600 upwards depending on the individuals assessed need. The fee is determined by whether the needs for care are high, medium or low. The fees do not include the cost of items such as newspapers, toiletries, magazines, chiropody and sundry items and there may be charges for some transport, outingstrips and holidays. A copy of the Statement of Purpose is available from the office. Copies of our inspection reports are displayed in the entrance hall. Care Homes for Adults (18-65 years) Page 3 of 10 What we found:
This inspection was completed in January 2010 to follow up on requirements issued at the last key inspection in September 2009 when the home moved from a poor rating to an adequate rating. We had requested an improvement plan from the home and they said that all requirements would be complied with by 31st December 2009. We examined evidence to support this including person centred plans,risk assessments,staff files,quality assurance records and a walk around the environment. One person discussed their care plan with us and how their needs were being met. Care plans and other records for all people living in the home had been rearranged providing easy access to information for staff. Out of date records had been archived. Each person had two working files one for daily records and the other for care plans and assessments, risk assessments and historical information. This was a considerable improvement to record management, ensuring that information was accessible and relevant. New person centred plans were being prepared with people. A person said they had talked to their key worker about what they wanted to do and that some of these goals had already been completed. Another person described how their key worker had supported them to research into their family background. The new format prompts people to record their wishes, needs, how these are going to be met and also identifies risks. Individual assessments focused on peoples physical, cultural, spiritual, psychological and social needs and preferences. There was evidence that the Mental Capacity Act and Deprivation of Liberty Safeguards had been considered. One plan had been signed by the person and their key worker and had also been dated. This is good practice. Another plan was still being developed and had not been signed or dated. There was evidence that where people needed support when anxious or distressed proactive and reactive strategies were in place. The manager confirmed that staff had completed training in the management of challenging behaviour in November 2009. Staff had not yet received their certificates and we were not provided with evidence that this training had been completed during this visit. Risk assessments had been put in place for each person in relation to using the community, environmental risks around their home and individual fire risk assessments. Considerable improvements had been completed to the environment since our last visit. New sofas had replaced worn furniture in the lounge, laminated floor had been layed in a first floor corridor, a shower had been refurbished and a shower curtain replaced a broken screen in another bathroom. One bathroom on the first floor was currently out of use. A ground floor bedroom had been refurbished for one person who had moved from their first floor bedroom after developing mobility problems with the stairs. A medication cabinet had been installed in the office and a fan fitted to make sure the temperature in this room remained below 22 degrees centigrade. The manager said that discussions were due to take place with people living in the home about the change of use of the dining room and lounge to create two rooms which would provide lounge/dining facilities. Presently some people chose to eat in the lounge and had been provided with trays or small tables. Staff had also recognised times when people wished to spend time together in the lounge rather than their rooms but not necessarily with everyone else in the home. The use of the two rooms in this way would they thought meet peoples current needs. There was some damage to the walls in the dining room. Problems with the floor in the new wet room had been resolved and this was now fully functional. New white goods
Care Homes for Adults (18-65 years) Page 4 of 10 such as a tumbledryer and a cooker had been purchased. We examined the files for two new members of staff appointed since our last visit. Each had completed an application form and provided an employment history. Where there were gaps in employment history the manager had queried this with them and provided evidence of a full employment history. He confirmed this information was obtained prior to appointment. The application form also requested information about peoples health or any specialist needs. People had been appointed after receipt of a satisfactory Criminal Records Bureau (CRB) check. An Independent Safeguarding Association (ISA) Adult First check had also been completed. The CRB checks were being kept on staff files and we advised the manager to store these separately and securely from staff files in line with Data Protection Act reccommendations. Two satisfactory references had been obtained for one member of staff, but only one reference was in place for the other. We reminded the manager of the need to obtain two references prior to appointment for new staff. Reference requests now ask the referree to provide the reason for leaving their employ. The manager confirmed that he requests references from the head office or human resources departments of previous employers and not from personal addresses when these have been provided by applicants. This is good practice. The manager confirmed that his CRB check had been returned and that his application to become registered with us had been sent to the provider to forward to our Registration team for processing. The manager shared with us work in progress towards developing a Quality Assurance Programme. Between September and December 2009 he had sent out surveys to people living in the home, their family and friends and staff. From these responses he would develop a report and a development plan for the home. We discussed other audits in place completed by staff for areas such as medication and health and safety. The last Regulation 26 visit to the home had taken place in October 2009 by the provider, no other visits had been completed since then. What the care home does well: What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2.
Care Homes for Adults (18-65 years) Page 5 of 10 Care Homes for Adults (18-65 years) Page 6 of 10 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action 1 6 15 The Registered Person must 31/12/2009 ensure that care documentation is person centred and reflects the individuals assessed and changing needs and personal goals for their health, safety welfare and lifestyle. (This requirement is repeated. Timescale of 1/3/08 and 30/09/09 not met, although there is evidence that work is in progress to meet this requirement) In particular, the Registered Person must ensure that all Person Centred Plans: - Fully involve the service user. Are clear and concise and jargon free. Clearly identify the prioritised goals and objectives that staff should be aware of for the people concerned. This will inform and underpin practices within the home. 2 32 18(1a) The Registered Person shall 26/02/2010 ensure that all staff have the skills to deal with incidents of
Page 7 of 10 Care Homes for Adults (18-65 years) Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action aggression and challenging behaviour and protocols for dealing with such episodes are documented. (This requirement is repeated. Timescale of 1/3/08 and 30/09/09 not met, although there is evidence that progress is being made to meet this requirement) This is to ensure that people in the home are supported in a safe and appropriate manner. 3 39 24 (1-3) The Registered Person must 31/12/2009 develop the homes quality assurance system by reviewing its performance and writing a quality assurance report to demonstrate continual improvement and development in the service. (Work is in progress to meet this requirement. Timescale of 31/3/08 and 30/09/09 not met) Care Homes for Adults (18-65 years) Page 8 of 10 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action 1 34 19 The registered person must 26/02/2010 make sure that two satisfactory references are in place before new staff are appointed. This is to protect people from potential abuse. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 1 2 3 6 24 34 Records should be signed and dated. Make good damage to dining room walls. Store CRB separately and securely from staff files. Care Homes for Adults (18-65 years) Page 9 of 10 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 10 of 10 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
