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Inspection on 18/11/05 for The Retreat, Quedgeley

Also see our care home review for The Retreat, Quedgeley for more information

This inspection was carried out on 18th November 2005.

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 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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service users spoken with said they liked living at The Retreat and some have been at the home for many years. The home has spacious outside areas, which offer the residents opportunities for leisure and relaxation. The home is close to local facilities and the service users said they are making regular use of nearby pubs and cafes for meals out. There are regular service users meetings where people are given the opportunity to discuss matters which are important to them.

What has improved since the last inspection?

Most of the requirements made in the last report have been completed. And progress made towards others. This has been taken into account when writing this report. The Complaints procedure has been reviewed and now provides most of the required details of the process. The manager has instructed the staff to ensure all the necessary records are maintained. Communication within the staff team is also being improved. New files are being set up for all the residents to hold basic information, care plans and assessments, copies of reviews, health records and family contact. People`s views about the care their receive are being sought as much as possible. Staff have been enrolled on the relevant NVQ courses.

What the care home could do better:

The Statement of Purpose and the Service Users Guide documents which provide information about the service and facilities in The Retreat need to be finalised. Improvements need to be made to the information about people` s support needs so that staff know what help to provide do and do this consistently. Confidential information in the home needs to be stored securely at all times. There are limitations on space for storing records and consideration should be given on how this can be improved. There are shortfalls in health and safety practices in the home and these need to be addressed so that the home complies with the relevant legislation and provides a safe environment for the service users.

CARE HOME ADULTS 18-65 The Retreat 116 Bristol Road Quedgeley Gloucester Glos GL2 4NA Lead Inspector Ms Tanya Harding Unannounced Inspection 18th November 2005 13:00 The Retreat DS0000060002.V267329.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 DS0000060002.V267329.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 DS0000060002.V267329.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Retreat Address 116 Bristol Road Quedgeley Gloucester Glos GL2 4NA 01452 728296 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) Mr Grant Marcus Taylor Care Home 14 Category(ies) of Learning disability (13), Learning disability over registration, with number 65 years of age (1) of places The Retreat DS0000060002.V267329.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2005 Brief Description of the Service: The Retreat is a large detached property in Quedgeley providing accommodation for up to fourteen adults with learning disabilities. The home is staffed at all times. Service users are accommodated in single rooms, some with ensuite facilities. The home is located close to a supermarket, post office and other facilities and is on a bus route. Gloucester city centre is approximately three miles away. A large lounge and a separate dining room are provided on the ground floor. There is a substantial garden, which includes an outdoor swimming pool. The Retreat DS0000060002.V267329.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken over six hours and ended at 19.00 hours. The acting manager was present throughout the inspection. The proprietor showed the inspector systems for managing service users finances. The inspector talked to a group of residents as well as individually with three service users. Several of the service users were out at day centre at the beginning of the visit. Towards the end of the visit all of the service users returned to the home and the inspector was able to greet them. Several staff were also present and assisted with some questions. The inspector spoke to one relative who was visiting the home. This report should be read in conjunction with the previous report for the home to present a better overview of the service provided. One complaint has been brought to the attention of the CSCI and the summary and outcome of this is included in this report. What the service does well: The service users spoken with said they liked living at The Retreat and some have been at the home for many years. The home has spacious outside areas, which offer the residents opportunities for leisure and relaxation. The home is close to local facilities and the service users said they are making regular use of nearby pubs and cafes for meals out. There are regular service users meetings where people are given the opportunity to discuss matters which are important to them. The Retreat DS0000060002.V267329.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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 DS0000060002.V267329.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 DS0000060002.V267329.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 The information about the service has not yet been completed to the required standard. EVIDENCE: The manager advised that she has not been able to complete the Statement of Purpose and the Service Users Guide for the home as yet and in view of the difficulties described by the manager, a new timescale has been agreed for this to be completed. The previous documents (as found by the acting manager) were insufficient for their purpose. At the time of the visit there was one vacancy in the home and the manager said she was considering referrals. The current residents are all funded by Gloucestershire Social Services. Evidence of a placement review was seen on one file. On the day of the inspection a review was taking place for another service user between the home and the day care service. The service user and their relative were in attendance. One person has additional mental health needs and at the time of the visit the service user was displaying some challenging behaviours. Staff did respond in a calm way. However, some records seen in the home would suggest that some staff may not always understand the effects and implications of mental health and there may well be a need for further training in this area to ensure that the approach is consistent and effective. The Retreat DS0000060002.V267329.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, 9 and 10 There are shortfalls in care plans and risk assessments, which mean that people’s needs may not be appropriately identified and supported. EVIDENCE: The quality of care plans and risk assessments was discussed with the manager. New care files are being set up for all residents and these will contain the relevant and up to date information about people’s needs. Sample files were seen. These contain basic information; care assessments, review documentation, health monitoring records and details of contact with relatives. There are plans to include photographs on each file. Risk assessments are being compiled as necessary. Care planning approach should be person centred and it is difficult to see how the current paperwork would support this. Care plans and risk assessments need further improvements as detailed: 1. Care plans are headed as ‘problem 1,2 and so on’ and this terminology is not seen as the most appropriate way to identify someone’s need for support. 2. Some care plans are very brief and do not provide sufficient details of what support is necessary. For example a care plan about supporting The Retreat DS0000060002.V267329.R01.S.doc Version 5.0 Page 10 3. 4. 5. 6. 7. social contact did not provide information about frequency of visits and how these are facilitated. One care plan was headed ‘chronic behaviour problem’. But the detail in the text referred to the support needed with personal care. Risk assessments were quite limited in the information provided. Information on one file stated that the person has severe learning disabilities. This is different to the formal diagnosis of mild learning disabilities for the person. This needs to be clarified and corrected. Care plan which talks about management of behaviours for one person talks about staff giving the service user clear directions of what is not acceptable. However, there are no details about what is it that the person does which may be identified as unacceptable. The guidance for staff needs to be more detailed as without this staff may adopt different responses to situations and this would be difficult to monitor and could lead to abusive practices developing. Incident recording needs to be improved by introducing the ABC format (antecedent; behaviour and consequence). Following an incident during which one person left the home without notification, a door alarm has been installed on the back door and risk assessments for the service user have been reviewed to ensure the person receives the right level of supervision and support. Consideration is also being given to other security features around the home. It was noted that the offices where majority of the service users records are stored were opened throughout the inspection. This has been brought to the attention of the manager and a requirement is made to store personal information securely at all times. The Retreat DS0000060002.V267329.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): 12, 16 and 17 Service users are able to take part in activities, which promote independence and enhance their lives. EVIDENCE: A number of the service users regularly attend day centres, where they have opportunities for social and educational activities. There are opportunities in the home for the residents to get involved in cooking, cleaning and other household tasks. On the day of the visit one resident was getting assisting staff in the kitchen. No obvious restrictions were observed with residents having free access to the their private areas, all of the communal areas, the kitchen, laundry room and the garden. It was noted that at least four of the residents do not have any formal day activities. One person has stopped their attendance to a day centre on what they explained to the voluntary basis. Another person has been asked not to attend after an incident. This should be monitored to ensure people are suitably occupied. The Retreat DS0000060002.V267329.R01.S.doc Version 5.0 Page 12 A volunteer was supporting one person with a tabletop game and the service user was clearly enjoying this. It may have been more appropriate to play the game on a large table rather than on the floor as the service user could not turn some of the cards over independently and relied on staff support for this. People are supported to pursue their hobbies and interests. One person was making beads with a bead kit from a craft store. One service user told the inspector they spend three days a week on a farm and use public transport for some of their trips. The staff spoken with did not seem to know much information about the farm. The staff team should be taking an active interest in what the service users do and enjoy as this promotes good relationships. There is a four weekly menu. The manager advised that detail of the food served is recorded on daily choices sheets. There were very few fresh ingredients in the home on the day of the visit and frozen vegetables were seen to be being prepared for the evening meal. The manager said that there are local deliveries of fresh fruit and vegetables to the home, to ensure rotation of stock and variety. This will be checked at the next inspection. Staff stated that service users are asked on daily basis about what they would like to eat and alternatives from the set menu are offered as necessary. The Retreat DS0000060002.V267329.R01.S.doc Version 5.0 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): 18 and 19 Improvements need to be made to information about supporting people with personal care and about people’s health needs to ensure service users receive consistent care and the necessary medical attention when required. EVIDENCE: There is information in care plans about support needed with personal care although in some cases information is not complete. For example for one person nothing was said about oral hygiene. There are specific care plans about people’s needs with regards to accessing GP’s and other health related appointments. Accident book was not examined on this occasion. A record was seen of one service user having a fall on 17/11/05 and of having a sore on their foot. It was not clear from this whether the person had hurt themselves during the fall and there were no reports as to whether any advise has been sought from the medical professionals regarding the fall and the sore. These issues must be followed up to ensure that the service user receives the necessary support and attention as appropriate. The Commission was not notified of the above incident as necessary under Regulation 37. The Retreat DS0000060002.V267329.R01.S.doc Version 5.0 Page 14 Other incidents were noted which should have been brought to the Commissions attention. Namely one on 6/11/05 when the service user was admitted to A&E with a foot injury and another one on 8/11/05 following aggression at the day centre, when physical intervention was used. The manager also advised of a recent hospital admission for one person for which she was planning to complete a Regulation 37 notification. There was evidence that medical advice has been sought for the person and this included a medication review. Some service users have mobility difficulties as observed during the inspection. Two service users are provided with walking aids. Mobility assessments were not evident on files and it should be established whether these have been done or require to be done. One service user has a specialist health need and told the inspector that staff in the home would know what to do if the person became ill. The person also said that if they get a headache, they tell staff and take a painkiller. Medication administration systems were not assessed on this occasion. With reference to the requirement made in the last report about reviewing protocols for ‘as required’ medication the manager explained that these are no longer relevant as the service user has moved on. The Retreat DS0000060002.V267329.R01.S.doc Version 5.0 Page 15 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 Changes in the management of the home may have contributed to a period of unsettlement and inconsistencies in practice and communication, thus resulting in complaints. Improvements to the existing adult protection, complaint and financial policies should offer greater protection to the service users. EVIDENCE: There have been two complaints about the service since the last inspection. Both complaints were from relatives and talked about care issues. The Commission has undertaken an investigation into one complaint and the home manager has investigated the second complaint. The complainants have not been satisfied with the outcome of this and the complaint is now under review by the Commission. The outcome of this review will be included in the next inspection report. Below is the summary of the findings and outcomes from the complaint investigated by the CSCI. Complaint summary: The complaint was in three parts and focused on the care and attention given to a specific service user in July 2005. 1. Part of the complaint about service user’s health being neglected was not upheld, as there was no evidence that the home have been negligent. The home was asked to consider whether they should have provided some staff support for the service user during the stays in hospital. 2. Part of the complaint about neglecting personal care needs of a service user was unresolved. This is because there was no evidence of intentional neglect, The Retreat DS0000060002.V267329.R01.S.doc Version 5.0 Page 16 but recognition that the home was struggling to meet the needs of the person and may not have managed their personal care needs appropriately at all times. The placing authority also identified this and the service user has now moved to a more suitable placement. 3. Part of the complaint about shortfalls in medication administration practices has been upheld. Requirements have been made for the home to improve their procedures to ensure information about medication and amounts administered is received, communicated and recorded correctly. The manager said that representatives from the local advocacy service have been to the home to talk to the staff about the service they offer. The manager has updated the Complaints procedure and a copy has been provided to the Commission. Information about how staff member can raise concerns should be added to the policy. Since the last inspection staff have received training in Protection of Vulnerable Adults. The manager hopes to complete the policy about prevention of abuse by end of December 2005. This should include details of the Local Adult Protection procedures. Information on how to obtain this has been given to the home. One person has behaviour challenges and on the day of the visit staff had to deal with two incidents of aggressive and loud behaviour. The service user has been asked not to attend their day care placement because of these issues (also see Standards 1-5). Staff explained that there is an agreed behaviour management approach following consultation with a psychiatrist based on a positive reward system and that this is not used in a punishing way. The proprietor has retained the responsibility for managing all of the financial transactions in the home. The systems for managing business moneys and personal moneys for service users are clearly distinguished and all income and expenditure is recorded. The proprietor explained that there have been difficulties in setting up individual bank accounts. This is linked to new legislation. It is possible that some service users could set up their own accounts without the need for a third party involvement and this should be explored with those individuals. It is also recommended that clarification be obtained from the homes’ insurance company about keeping cash on premises. Expenditure by service users is itemised and receipts are kept. It was noted that when service users have meals out, they also pay for staff. The arrangements for what the residents are expected to pay for and any additional contributions need to be stated in the Statement of Purpose and the Service Users Guide. This information also needs to be added to the homes policy on managing personal finances. The Retreat DS0000060002.V267329.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed. EVIDENCE: The manager spoke about the improvements which are needed in the vacant bedroom. This includes installing a sink and replacing the radiator. It is anticipated that this will be done before a new resident moves in. Three of the rooms were visited with the service users’ permission. The rooms were personalised with people’s possessions. The radiator in one room did not heat up when the other radiators were on and this was pointed out to the manager. Three service users showed the inspector their bedrooms and all said that they were happy with the facilities they have. The Retreat DS0000060002.V267329.R01.S.doc Version 5.0 Page 18 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 There are inconsistencies in staff practices and value base which may compromise the quality of the support provided to the service users. EVIDENCE: Concerns have been raised about staff approach in the complaint to the home. The manager has taken action to reinforce good practice principles to the staff. On the day of the visit some positive interactions were observed between staff and service users. One staff member had been out buying Christmas presents for the residents earlier in the day. When asked how did the home know what people wanted as presents, the staff member replied ‘ We ask them’. This is a good example of an inclusive value base, which is so important in any care home. However, the inspector also observed practices which were controlling and unprofessional and this has been brought to the attention of the manager. One example of this was the way one service user was told that they would not go out if they continued to behave the way they were at the time. This is an example of staff making a direct threat to the person and this is both inappropriate and unprofessional. In addition to this the use of endearment terms such as ‘darling’ and ‘love’ towards the service users should be avoided and people’s names (preferred terms of address) should be used and recorded on personal files. The Retreat DS0000060002.V267329.R01.S.doc Version 5.0 Page 19 Daily records which are completed by support staff were sampled. On the whole, these present a short overview of the days events. It was noted that some records were not factual and could also be seen as derogatory. For example a record made on 10/11/05 said ‘the service user has been cleverly winding other residents up by saying things to them, usually insults and denying when confronted by staff’. This record presents a very negative view of the service user and a personal opinion of the individual staff member rather than a factual account. In terms of good practice records should distinguish between fact and opinion. From this it would be easier to identify what the actual issues were and who was affected. The manager advised that all of the staff have now enrolled onto NVQ2. One person is doing NVQ3. On the day of the visit, one staff member was being visited by an external NVQ assessor who carried out an observation of staff administering medication. Staff have completed POVA training and the manager has agreed to check on who has provided this training. The manager also plans to deliver training to staff about activities, which will include a functional performance assessment. This is planned for the New Year. Other training requirements will be assessed at the next visit. Consideration should be given to more specialist training in areas of mental health and management of challenging behaviours. The inspector was informed that there are three staff on duty at any one time (apart from nights). The manager also works full time. Additional staff are asked to work if there is a planned trip out. At the time of the inspection 14 staff were employed in the home and the inspector requested that updated information about staff and residents be provided through completion of a preinspection questionnaire. There is a large number of service users in the home with different needs and the manager would need to monitor closely the appropriateness of staffing levels to ensure people’s assessed needs are being met. The Retreat DS0000060002.V267329.R01.S.doc Version 5.0 Page 20 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 and 42 Shortfalls in health and safety practices in the home could compromise the quality of the service and put service users at risk. EVIDENCE: The manager is still very new to the home and is yet to be registered with the Commission. An application in respect of this has been received. Service users were observed talking with the registered provider and with the manager, who took their time to communicate with people in a respectful manner. Health and safety matters: The manager is working on compiling environmental risks in the home, for example when the kitchen floor gets wet. The risk assessment was examined for the outside swimming pool. The robustness of this document needs to be checked with the Environmental Health Department to ensure all relevant risks have been considered. The Retreat DS0000060002.V267329.R01.S.doc Version 5.0 Page 21 Radiators seen have thermostatic controls which people can turn up and down themselves. None of the radiators seen were covered. This must be risk assessed in line with health and safety guidance on risks from hot surfaces and pipes. Some individuals may be at significant risk because of their cognitive abilities, mobility difficulties or health issues. Uncovered radiators in certain areas of the home such as bedrooms and bathrooms, may present greater risk as these are the areas where staff are present less frequently. These factors must be taken into account when compiling the necessary risk assessment. The manager advised that she has completed a generic risk assessment course and a health and safety course. She has provided training in this to other staff. There were a number of files in the kitchen area which contained formats for recording of fridge and freezer temperatures and food probe tests. However, the record sheets for fridge and freezer temperatures were not completed. There are two fridges and two freezers in the home and temperatures of these appliances need to be checked regularly. Food probes – there were two entries and these were not dated. Some food which has been removed from its original packaging and stored in the fridge was dated. However, some corned beef was seen in a plastic bag and this was not labelled or dated. Some bedroom doors were propped open on the day of the visit. The home needs to consult with the Fire Authority about the best practice in fire safety. The Retreat DS0000060002.V267329.R01.S.doc Version 5.0 Page 22 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 2 x x x x Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 x 2 2 Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 x 12 3 13 x 14 x 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Retreat Score 2 2 x x Standard No 37 38 39 40 41 42 43 Score 2 X X X X 1 x DS0000060002.V267329.R01.S.doc Version 5.0 Page 23 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 YA1 Regulation 4,5 Requirement Complete the revision of Statement of Purpose and Service Users Guide and supply copies of these documents to the Commission. (Timescale of 30/09/05 not met). Information in care plans needs to be correct, detailed and informative to ensure staff have the necessary guidance on how to support individuals respectfully and consistently. Individual risk assessments need to be based on people’s assessed needs and provide sufficient detail about risks, hazards and actions required to reduce or eliminate these. (Original timescale 30/09/05. Some progress has been made). Establish whether medical advice has been sought for the service user who had developed a sore on their foot. Relevant records about this and any other medical matters must be kept for all service users. Ensure the Commission is notified of events which may adversely affect the wellbeing of DS0000060002.V267329.R01.S.doc Timescale for action 31/01/06 2 YA6 15 31/03/06 3 YA9 13 (4) 31/03/06 4 YA19 12 31/12/05 5 YA19 37 15/12/05 The Retreat Version 5.0 Page 24 6 YA23 13 7 YA23 12 8 YA32 12 9 YA42 23 10 YA42 23 11 YA42 23 12 YA10 12 and 13 the service users in line with Regulation 37. Policy setting out adult protection procedures in the home must be completed and a copy forwarded to the Commission for reference. Details of what service users are expected to contribute towards (other than the agreed residential fee) need to be added to the home’s policy on managing of service users’ finances as well as to the SOP and Service User Guide. The manager must ensure that all staff treat service users with dignity and respect at all times. Action must be taken in response to poor and unprofessional practices if these are identified. This includes follow up to any inappropriate written records made. Ensure systems for monitoring health and safety in the home are in place and are being followed by all staff (this includes monitoring of fridge/ freezer temperatures, water temperatures, food temperatures and hazard analysis of the environment). Carry out a consultation with the Environmental Health department about the risk assessment for the swimming pool and good food storage practices. Carry out a consultation with the Fire Authority about fire safety measures in the home (including propped doors). Review systems in place for storing of confidential records and ensure that all personal information is stored securely at all times. DS0000060002.V267329.R01.S.doc 15/01/06 31/01/06 15/12/05 31/12/05 31/01/06 31/01/06 15/01/06 The Retreat Version 5.0 Page 25 13 YA20 13 (2) 14 YA18 12(1) Handwritten medication records 07/10/05 must be checked with the prescription before the staff member signs the medication administration record. (Requirement from the complaint investigation). The home must introduce 31/10/05 monitoring forms to monitor, review and evaluate the personal and health care needs of service users. (Requirement from the complaint investigation). 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 2 3 4 5 Refer to Standard YA6 YA6 YA6 YA12 YA18 Good Practice Recommendations Paperwork used for recording care plans should be amended to remove inappropriate terminology as described in the text. The home should introduce person centred approach to care planning. Incident recording should be improved by introducing Antecedent/ Behaviour and Consequence charts. Access to activities for people who do not have regular day care should be monitored to ensure people do not miss out on opportunities to socialise and pursue their interests. Check whether mobility assessments have been completed for the service users with mobility difficulties and that these are present on people’s files. (If not found – these assessments must be completed). Information about how staff would complain or raise concerns should be added to the Complaints procedure. Service users who are able to open their own bank accounts should be supported to do this. Clarification about keeping cash in the home should be obtained from the relevant insurance company. The use of endearment terms should be avoided. Staffing levels should be monitored to ensure these are appropriate to the needs of the service users. Handwritten medication records should be checked and DS0000060002.V267329.R01.S.doc Version 5.0 Page 26 6 7 8 9 10 11 YA22 YA23 YA23 YA32 YA33 YA20 The Retreat 12 13 YA22 YA19 countersigned by two people. Family and service users should be given a copy of the complaints policy and procedure. Health Action Plans should be introduced for all service users. The Retreat DS0000060002.V267329.R01.S.doc Version 5.0 Page 27 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. 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