Inspection on 24/03/09 for The Retreat, Quedgeley

This inspection was carried out on 24th March 2009.

CSCI found this care home to be providing an Poor 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 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Retreat, Quedgeley 14/01/10

The Retreat, Quedgeley 08/09/09

The Retreat, Quedgeley 31/03/08

The Retreat, Quedgeley 06/07/07

The Retreat, Quedgeley 09/08/06

The Retreat, Quedgeley 18/11/05

The Retreat, Quedgeley 09/03/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Key inspection report CARE HOME ADULTS 18-65 The Retreat, Quedgeley 116 Bristol Road Quedgeley Gloucester Glos GL2 4NA Lead Inspector Odette Coveney Key Unannounced Inspection 24th March 2009 09:00 The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought 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. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) 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. www.cqc.org.uk Internet address The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Retreat, Quedgeley 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) manager@retreatgloucester.co.uk Mr Grant Marcus Taylor There is currently no registered manager in post. Care Home 14 Category(ies) of Learning disability (13), Learning disability over registration, with number 65 years of age (1) of places The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: No conditions recorded. Date of last inspection 31st March 2008 Brief Description of the Service: The Retreat is a large detached property on the Bristol Road in Quedgeley providing accommodation and personal care for up to fourteen adults with learning disabilities. The home is staffed twenty-four hours a day and has waking staff at night. People are accommodated in single rooms on ground and first floor levels, some with ensuite facilities others with handwash basins or shower cubicle washing facilities. Rooms on the first floor are accessed via stairs; 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 that people use during the good weather and a substantial garden that is laid to lawn. The lawn area is not accessed by people at the present time, as there is an outdoor unused swimming pool area that needs maintenance. There is a car park for several cars to the front and side of the property. The home is located close to a 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 for personal care at The Retreat range from £450 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, outings/trips and holidays. The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is zero star rating. This means the people who use this service experience poor quality outcomes. The key inspection was undertaken in line with the Care Standards Act 2000 and following the Commission’s Inspecting for Better Lives guidance. The purpose of the visit was to review the progress to the requirements and recommendations from the last key visit undertaken by us on 31st March 2008. This was an unannounced key visit, which took place over two days, by one inspector; the manager was present throughout the inspection. As part of this inspection a number of documents were examined including care plans, risk assessments and those relating to staffing and training. Also examined were the arrangements for managing medication and recruitment and selection of staff. Prior to our visit we received a completed Annual Quality Assurance Assessment (AQAA), this had been completed by the manager and forwarded to The Commission prior to the visit. The AQAA that had been completed was for services for older people, not for young adults and therefore the home were not able to provide sufficient information in order to fully demonstrate to us within this document how all of the National Minimum Standards for young adults would be met. There was an opportunity to discuss with people living at the home and staff about their experiences of living and working at The Retreat. No visitors were present during our visit and therefore we were unable to obtain their views about the service. What the service does well: The Retreat provides a relaxed, friendly and homely environment and individuals spoken with confirmed that they are happy living in the home. Daily routines appear flexible and staff accommodate individual lifestyle choices, whilst enabling individuals to remain as independent as possible. The overall impression following the visit was that the individuals living at the home are happy, settled and secure and the staff have a good rapport with them. Staff are well trained in all core areas and receive regular formal, recorded supervision. Meetings are held on a regular basis with those who live and work at the home in order to gain their views about the service being provided. The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The homes statement of purpose and service users guide must be updated in order to ensure accurate information about the services and facilities provided by the home. Contracts or terms and conditions of the placement must contact correct information and must be in place for all who live at The Retreat and must clearly outline the rights and responsibilities of the service provider. Person centred records within the home, which were examined by us, still lacked clarity, and were written in a jargonistic manner and did not provide clear instruction on how to care for people. Not all care plans had been kept under review and updated where required. Care documentation must inform and underpin care practice within the home and it does not at the present time. This is a repeated requirement. Standards of recording within this area must be improved. It is further required that care plans must be kept under review to ensure that the information held is accurate and reflects the assessed needs, wishes and choices of individuals who live at the home. In order to demonstrate that staff have an understanding of individual’s needs and behaviours and also to ensure that individuals are being treated with dignity and respect, it is required that consideration be given to the use of language within individual’s daily records. The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 7 Attention must be given by the registered person to the areas identified within the environmental section of this report, (there are a number of outstanding issues) which must be addressed in order to ensure that the home is safe and is being well maintained for the people who live in the home. In order that people have clear, accurate information it is recommended that the homes complaints procedure is updated in order that correct information is provided for people about the address of The Care Quality Commission. There needs to be clarity in the role and responsibilities of the Manager and the Provider, so that issues relating to maintenance and Quality Assurance do not get ‘missed’ and are auditable with clear lines of responsibility and accountability. This is also of particular importance with regard to regular auditing of health and safety issues which, unless properly audited and actioned, may have a direct impact on the safety of people who live at the home. When reviewing records for people who live at the home we noted that ‘residents property registers’ had not been reviewed and saw that the information contained within them was incorrect and out of date. These documents must be reviewed and updated in order that clear, audited information is maintained of people’s valuables and property. It is also required that receipts are obtained when a person receives a service, such as chiropody in order to evidence that the service has been provided and at what costs. During this key visit to the service we read recent reports, which had been completed by the Environmental Health Department and Health and Safety Executive. Within these reports recommendations were made in order to protect and keep people safe in the home. It is required that the home must comply with the recommendations which have been set by these external regulatory bodies and take appropriate action as needed to ensure the health, safety and welfare for people who live and work at the home. During this visit concerns were noted over fire safety, an immediate requirement was made in order that attention is given urgently to two fire doors, which were deemed to be unsafe. A further requirement was made that the registered person must consult with the fire authority to request an inspection of the premises in order to ensure that all safety measures are in place should a fire occur. We also required that the registered person review and update, as needed, the fire risk assessment, with particular attention to be given to how people would be supported to evacuate the home should a fire occur. During this visit we reviewed risk assessments in place in respect of household activities, we saw that a number of assessments were in place, these contained sufficient detail, however many of these documents had not been reviewed since 2007, some as long ago as 2005. These must be reviewed, and updated where required in order to ensure that they are robust and contain correct information. The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 8 During this visit we noted that the home does not monitor or check the hot water temperatures. In order to ensure that hot water temperatures for people living in the home are safe it is required that the home maintains a record of checks to evidence that this area is monitored. The home has gone through a period of change due to their being a different manager in post. Some improvements have been made and still need to be made. As a result of this, people’s needs are beginning to be met more effectively There are requirements and one recommendation in respect of previous visits made by us, which have not been met by the home. We will be requesting that the registered provider sends to us a detailed improvement plan, including timescales which must inform us how the home is intending to meet the requirements and recommendations which have been set in order that outcomes for people who live at the home can be improved. This must be a priority for the registered person. 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 9 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, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 4. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Those living at The Retreat and also prospective residents do not have the information they need in order to make an informed choice about the home and the services and facilities provided. Contracts, which outline individual’s terms and conditions of their placement, are not in place and must be provided for all who live at The Retreat. EVIDENCE: The Retreat is registered with the Care Quality Commission to provide residential care for 14 adults with a learning disability. At the time of our visit 12 people, male and female, were accommodated at the home. One person living at the home is over the age of 64. There are currently two vacancies. There have not been any new admissions to the home for some time and therefore the process for new admissions was not fully discussed at this visit. When we last visited the home on 31st March 2008 we reported that the homes statement of purpose and the service users guide were in the process of being updated. At our last visit to the service a requirement was made that amendments were needed to the service users guide and statement of purpose in order to ensure that this document provides clear and accurate information. The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 11 It was required that when updated the documents must reflect the changes in the home, it must inform the reader of the status/plans for the swimming pool area and must also be available in a variety of formats suitable for individuals who may reside at the home. We reviewed these documents at this visit and although we saw that the documents had been updated in order to reflect that there was a new manager in position, the changes, which had been required by us, had not been met. At this visit the manager also confirmed to us that there had been no amendments to the statement of purpose or the service users guide and that these documents had not been fully updated to reflect the required changes. The requirement remains. During our last visit to the service we also noted that two of the bedrooms were identified as being fairly small and reported that these rooms should be checked to see whether they are under the minimum size requirements and if so this should be recorded in the home’s statement of purpose. When we spoke to the manager and staff it was evident they acknowledged that these rooms appeared smaller than what was required, however, they had not been measured. During this visit we measured these rooms and found them to be less than the required minimum of 10sq metres of useable floor space. One of the rooms is currently vacant and is being used by staff as the sleep in area; the other room is being used for someone who lives at the home. Whilst we acknowledge that we would not expect the individual to move out of their room it remains that the home must be open and transparent about the size of these rooms and this must be recorded within the homes statement of purpose and service users guide. At our last visit we recorded that the proprietor needs to ensure that the homes’ contract contains all the required details and is compliant with the Office of Fair Trading Guidance. This document was found to be contained within the homes statement of purpose, individual contracts or terms of the conditions of their placement were not in place, these must be in place for all who live at the home in order that individuals can be aware of their rights and responsibilities and also of those of the registered provider. The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s plans of care do not reflect personal goals or needs, they are not person centred and do not demonstrate that the individual has been fully involved with their plan of care. Some people living at the home can make decisions about their lifestyle. Risk assessments are in place but some are not always sufficiently detailed in order to ensure people’s needs are met. EVIDENCE: During our last key visit to the service in March 2008 a requirement was made that The Registered Person must 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. In particular, the Registered The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 13 Person must ensure that all person centred plans fully involve the individual person that the plans are clear and concise and jargon free. We also reported that the care plans must clearly identify the prioritised goals and objectives for people living at the home and that staff should be aware of these for the people concerned. It is essential that care documentation contains full, accurate information about individual’s wishes, choices and support and that the plans provide sufficient guidance for staff in order to inform and underpin practices within the home. This requirement is outstanding, the previous timescale of 1/3/08 has not met. At this visit we reviewed the care, and all associated documents for four of the people living at the home. Within the front section of each persons care file was a statement, which had been produced by the former manager of the home. This stated that those living at the home had been consulted and had participated in the development of their care plan. This was not evident to us. We asked three people about their plan of care, and used differing terms to describe this document, none of the people we spoke with knew about their care plan. It also concerned us to see that the care plans were all written in the same format, with the same phrases and sentences used. It appeared to us that much of the care plans had been ‘cut and pasted’ from another person’s records. Within one persons care plan there were four sections, which referred to another person who lives in the home, we also saw reference about another persons care in a second persons records. This requirement has not been met. When we asked the manager she informed us that these care plans had been devised by the previous manager and that her intention had been to revise and update these documents in order to comply with the requirement which had been set, however, her attention and time has been taken by ensuring that peoples needs were met and to ensure that staffing issues were resolved within the home. Whilst we acknowledge that improvements have been made within the culture of the home care planning records and associated risk assessments have not been improved and do not meet the standard expected. Following a review of individual’s daily records it was noted that there was some use of inappropriate language in respect of how some staff described individuals behaviour. Therefore it is further required that consideration should also be given to the use of language within these records. In order to demonstrate that staff have an understanding of individual’s needs and behaviours and also to ensure that individuals are being treated with dignity and respect. At our last key visit we reviewed a previous requirement, this was that the registered person must ensure that where there are specific measures in place for dealing with specific behaviour these are recorded on the support/care record. At this visit we reviewed the records pertaining to an individual who had presented behaviour, which challenged staff and the police in the weekend before our visit. We saw that appropriate action had been taken at the time to support the individual and others who live and work at the home; the manager had contacted the local authority and had alerted the safeguarding manager The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 14 for the area. The manager had also contacted mental health professionals and the individual’s GP in order that they are supported with their health. We also saw that the manager was in the process of updating this person care records in order that guidance was in place to direct staff practice. We found this requirement to have been met. At this visit we reviewed a previous requirement that the registered person must regularly audit support care files to ensure that the correct information is recorded, dated, signed and that there is consistency of recording in the home. At this visit we found that the manager had reviewed information contained within the care file, historic information had been filed and information had been audited in order that current, required information was available, this requirement had been met. When we last visited the home we were concerned to find that information recorded about people living at the home was being held in the dining room, in a cabinet, which was not secure. A requirement was made that the home must ensure that confidential information is kept secure. At this visit we found that confidential documents are now stored in a room which can be locked. Individuals were observed walking around the home, and approaching staff. Residents looked reasonably relaxed and settled in their environment, staff were seen to be friendly and caring in their approach and interacted with people appropatiately responding to questions and engaging in conversation. The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 15 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): This is what people staying in this care home experience: 12, 13, 15, 16, 17. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home engage in appropriate leisure activities and are offered a healthy diet and enjoy their meals at mealtimes. EVIDENCE: During our last visit to the service a requirement was made that the Registered Person must ensure that all risks are clearly identified and that all reasonable safeguards and good practice are in place and documented. This is with specific regard to independent travel, use of wheel chairs and the security of the building. When we reviewed these assessments we found that they had been completed and covered areas of identified risk as required. Individuals who were able to express a view informed us that they could choose how and where to spend their day. They also confirmed that they decided what time they got up in the morning and retired to bed. During the The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 16 visit individuals were observed moving freely around the home. All had access to communal areas and their bedrooms. During the two days of our visit, we saw that people were doing things during the day. People were up and about making themselves snacks and drinks, helping staff with household chores, going out into the community, and approaching staff with ease. People appeared settled. One person said to us “I do like it here now, it feels like home, I like the staff.” During our time at the home we saw that people were busy accessing the community two people told us that they get the bus and that they have their own bus pass to enable them to have independent travel, another person told us that they were on their way out to the shops, another said they were going to the library. We saw in people’s records that they access sports and social clubs and participate in activities of their choosing. We also saw that people attend college, go out to day trips to places of local interest, discos, pubs and ‘The Rainbow Club’. On the first day of our visit one person told us about their job and how much they enjoyed their work and their pay. We saw that meetings had been held with those people who live at the home and that people were encouraged to give their opinion and suggestions from them were welcomed in order that improvements can be made in the running of the home. We saw that at the most recent meeting holiday choices had been discussed with people and the manager confirmed that these would be actively pursued and where possible facilitated by the home. We saw that people are encouraged to maintain relationships with family and friends; we saw within individual’s records that people go out with their relatives. People living at the home told us that they have visitors and that they are made welcome by the staff. The staff try to ensure the menus are nutritionally well balanced and varied, so that those living at the home are provided with a balanced diet. Recent Environmental Health Office checks have been satisfactory. The kitchen area appeared well managed, however, during our visit it was pork chops for tea we noted in the morning that these had been taken out of the freezer in order to defrost ready for the evening meal. In the afternoon we spoke with a member of staff who was preparing the evening meal. The pork chops were still frozen and the staff member was trying to defrost these by hot water being poured over the meat. This was reported to the manager who spoke to the staff member concerned and an alternative meal was provided. The staff member apologised for their actions. The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Medication administration and recording within the home are good, people access healthcare services as required. EVIDENCE: Information seen in care records, interactions observed between staff and those who live at the home, information recorded in daily diaries and risk assessments showed that guidance and support regarding personal hygiene is given when required and at a level and place appropriate to the people who live at The Retreat. All people who live at the home are registered with a local General Practitioner and information seen in records confirmed that individuals are supported in all aspects of their primary health needs such as chiropody, optician and dentist as well as other specialist areas of their health such as anxiety support, mental health and special diets. The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 18 From discussions with staff and information seen in care records it was evident that people at the home are supported to attend health appointments and records are completed after each visit. This ensures a consistent approach to meeting individual needs During this visit we reviewed medication practices at the home. This was found to be secure, systems of medication administration, recording and storage were found to be good. A disposal book was in place for medication that is no longer required and medication audits were in place for medication at the home. Staff informed us that they had attended training, which had deemed them competent to support people at the home in this area. A training matrix seen by us during this visit also confirmed staff training. There are no people in the home who are able to manage their medication independently; all are supported in this area. Individuals looked as if they had chosen their own clothes, hairstyle, makeup and their appearance reflected their personality and was appropriate to their age. The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home feel comfortable with raising concerns and feel that they are listened to. People are protected from abuse due to the policies and procedures in place at the home. EVIDENCE: Since the time of the last inspection no complaints have been made to the management of the home and none have been brought to the attention of The Commission. The home has a complaints log, where any complaints are logged, which we saw. This provided evidence that any complaints are recorded and investigated seriously. We spoke to a number of people living in the home and we asked two of them what they would do if they had any concerns or complaints. They told us that they would talk to the manager, or a member of staff. There are people living at the home who have communication difficulties and may not be able to verbally inform someone if they had a concern or complaint they wishes to raise. During our last visit to the service a requirement was made that The Registered Person must make the complaint/concerns procedure available in a variety of formats suitable for individuals who live at the home. A review of this document by us at this visit evidenced that the complaints/concerns The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 20 procedure had not been produced in any different formats. This requirement has not been met. We also noted that a copy of the homes complaints procedure was on display, however, it provided incorrect details of how people can contact the Commission, the notice informed people that they can contact the Commission at offices in Gloucester, these offices closed many months ago. In order that people have clear, accurate information it is recommended that the homes complaints procedure be updated in order that correct information is provided for people about the address of The Care Quality Commission. Prior to any members of staff commencing employment at The Retreat the Protection of Vulnerable Adults list is checked to ensure their suitability, the results of this check are always obtained by the home before staff begin working there. Since the last inspection visit the home has not made any referrals to the Protection of Vulnerable Adults list. All staff employed at the home have received training in the protection of vulnerable adults, staff we spoke to were able to demonstrate to us a sound understanding of their responsibility in this area. The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 30 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has standard furnishings and fittings, which provide a comfortable environment for individuals to live in; some improvements are required in respect of décor and maintenance. EVIDENCE: The Retreat is a large detached property on the Bristol Road in Quedgeley providing accommodation and personal care for up to fourteen adults with learning disabilities. The home is located close to a 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 Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 22 A tour of the property was undertaken. At previous visits there have been various issues with the home’s décor and maintenance. Within the last report we recorded that the environmental issues identified in the body of the report must be addressed, these were as follows: • The upstairs toilet in the rear extension had no light bulb and when this was replaced during the inspection it still did not work. The toilet seat was damaged and not properly secured and there was considerable dust around the pipes in the room. At the time of our visit, this and another toilet were out of action and were in the process of being replaced and therefore we were unable to review this area fully. Bedroom 12 has a lock on the door that is inappropriate, in that there is no override device on the outside. This door would also not close properly. At this visit we found that this door is still not closing, as it should and there was no lock on the door, therefore no provision for privacy was given. The corridor leading to this room is in need of decoration, with damaged plasterwork and flaking paint. The carpet was also in need of cleaning. At this visit we were informed that this area had been redecorated, the carpet still looked as if it would benefit from being cleaned. Bedroom 11 has damage around the skirting board and also a door that does not close properly. This was found to be the same at this visit, we further noted that the shower area within this room had loose tiles and there is a crack around the ceiling area, which should be investigated further and made good. In the downstairs back corridor two further rooms had doors that did not close properly. One of these was due to a piece of cloth being tied around the door, which is apparently due to the occupant repeatedly opening and closing the door. This room was very warm and has had a cupboard and shelves built onto the radiator. At this visit there was no cloth tied to the door, however, the door was still not closing properly. The carpet in the corridor downstairs was in need of cleaning and is badly faded in certain areas. The paintwork is flaking and decorating is required. At this visit we found that the paintwork had been refreshed and the carpet cleaned, however we noted that the radiator cover had a large whole in it, this needs repair or replacement. There was a folded put-u-up bed under the stairs with a pile of bedding stacked on top, which presents a fire hazard. At this visit this area was found to be clear. The bathroom on the ground floor was reasonably clean but there was no shower curtain in place and also the hoist seat plate had rust on it. At this visit we found this area to be the same. The bathroom on the first floor of the main house was reasonably clean but both taps in the sink were very loose and needed repairing, there was rust around the foot of the bath chair and there was no soap in evidence. This bathroom was in the process of being refurbished at the time of our visit. DS0000060002.V374946.R01.S.doc Version 5.2 Page 23 • • • • • • • • The Retreat, Quedgeley • • • • • • • In the adjacent shower room there again was no soap and also no plug in the sink. At this area these areas were found to be the same, we also noted that there was a shower panel missing in this area. The upstairs corridor has a fire door onto the landing and this has a keypad on it. It was stated that this was not used and therefore this should be removed as it provides the capacity for people to be accidentally or otherwise locked into this area of the house. One person commented that they had once been accidentally locked in this area. At this visit we found that this keypad had been removed. Bedroom 2 has a door that would not close properly. This was found to be the same at this visit. One person has an en-suite bathroom and a bedroom that is accessed through the bathroom. This bathroom contains a boiler in a cupboard; the cupboard door needs to have a secure lock fitted. We found at this visit that a lock had been fitted to this area. In bedroom 4 the light switch in the toilet did not work properly and the shower door was damaged and needed repair. At this visit the light was found to be working and the shower door closed as needed. The bedroom on the top floor had a door that would not close properly. This was found to be the same at this visit. Two of the bedrooms were identified as being fairly small and these should be checked to see whether they are under the minimum size requirements and if so this should be recorded in the home’s Statement of Purpose. These rooms were measured by us and were found to be smaller than the required minimum standards; the home had not recorded this within their statement of purpose and must do so. The above list included a number of doors that do not close properly, which compromises fire safety. An immediate requirement in respect of fire doors was issued during this key visit; see management section of this report. At this visit we also noted that the window on the first floor landing area had water within the double glazed panel, making the window misty and difficult to see through, attention should be given to this. At the time of our visit a contractor was on site providing a quote for the kitchen worktops to be replaced, in line with recommendations from the recent environmental health visit, see management section of this report. During our last visit to the home we made a requirement that The Registered Person must address the Health and Safety issues relating to the unused swimming pool area. This was due to concerns over safety as the pool area is partitioned off by sheets of wood that had been placed in the gaps in the wall to the swimming pool. The wall is in need of repair. We also reported that the height of the wall and the wooden sheets are only about 3 feet high and that the patio area around the pool presents a serious health and safety risk. The pool has been drained of water and is covered with a tarpaulin; it remains that The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 24 many of the paving slabs have lifted and the pegs locating the tarpaulin present. It remains our view that it would be relatively easy for people to access this area and action must be taken to provide greater protection and safety here. During our last visit to the service a requirement was made that The Registered Person must address the infection control issues relating to cleanliness in the home and also in ensuring hand washing and drying facilities are available in all parts of the home. At this visit we found there to be soap and hand towels available in all bathrooms and within individuals rooms and generally the home was found to be clean and tidy, however, we noted odour in some areas of the home. Attention must be given to find the source of this and action taken to eliminate odour. As reported within the section about choice of home it is noted that two of the bedrooms were identified, as being fairly small and information about this should be recorded in the home’s Statement of Purpose. The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 25 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34,35, 36. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing arrangements in the home are satisfactory so that the needs of people living at the home can be met in an efficient way. The recruitment and selection of staff is undertaken to make sure that as far as possible the health and welfare of individuals are protected, however staff must receive training in order to support people living at the home with complex needs whose behaviour may at times challenge staff. EVIDENCE: On the day of our visit, there was a friendly and interactive atmosphere in the home. Individual’s looked well cared for and were noted talking to staff in an informal way. Staff spoken with made complementary remarks about the manager and said they would approach her if there was any problem. Staff supervision was reviewed. Evidence from the records viewed showed that staff have received supervision. Staff spoken with confirmed that they have received supervision and that they benefited from the process. The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 26 During our last visit to the service a requirement was made that the Registered Person must ensure that robust recruitment procedures are followed, particularly with regard to obtaining references and a full employment history. At this visit we reviewed employment, recruitment and selection records for five staff members, including staff that had been recently appointed at the home. The records we looked at showed that the necessary checks are place i.e. 2 references and Criminal Records Bureau Check (CRB). Application forms provided full and detailed information about applicants including full employment history, as required. During our last visit to the home a requirement was made that the Registered Person should develop a documented training and development plan for all the staff at the home. At this visit we saw that the manger had developed a training matrix, which covered all of the training that had been completed or planned for all staff members. We saw that all staff either have completed, or are in the process of undertaking a National Vocational Qualification in care practices, promoting independence. All staff have attended protection of vulnerable adults awareness, first aid, food hygiene, fire awareness, manual handling and medication competency. Staff also confirmed to us that they were in the process of completing a distance learning pack in respect of infection control, staff told us they had learnt from the training and it had improved standards at the home. Training records were looked at and evidenced that those inspected had undertaken the mandatory areas of training; Mrs Mears spoke of future training plans for staff to include Epilepsy Awareness, Autism, Manual Handling, Deprivation of Liberties Safeguards and Mental Capacity Awareness. Progress in these areas will be reviewed at the next visit to the service. Staff require training on how to support people with complex behaviours who may present behaviours that can be a challenge, this has not been provided. Please see the management section of this report for further information about this area. We also reviewed the induction process for the most recent member of staff employed at the home. We saw that the induction had been completed in line with Skills for Care requirements and covered the common induction standards such as understanding the principles of care, understanding the role of the organisation and the worker, communicating effectively and maintaining safety at work. At our last key visit to the service we also wanted to ensure that staff had benefited from training they had received, a requirement was made that the registered person should ensure that they monitor the outcome of training to ensure that staff have understood the information given, and are applying it in their work appropriately. Staff we spoke with told us about training they had undertaken and informed us how this had improved and influenced their The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 27 performance at work. One member of staff spoke positively about manual handling training they had undertaken and told us of the contents of the training. We also saw that training, staff performance, roles and responsibilities had been discussed with staff during team meetings and also during supervision in order to check staff understanding, no concerns were noted. Morale is good within this home and staff spoke positively about their role and the work they do and were able to give a number of examples of areas within their role which gave them job satisfaction such as one to one time with individuals, supporting individuals in the way they prefer and building relationships based on trust. The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 28 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are health and safety concerns for people living in this home; action must be taken to make improvements this area. EVIDENCE: At the time of this visit the manager was Mrs J Mears, Mrs Mears has not registered with us at the manager of this service. Mrs Mears informed us that she was leaving the home and that a new manager had been appointed. When reviewing these standards a requirement was made by us following our visit to the service in 2007. The requirement was that the Registered Person should ensure that the culture of the care home is conducted in order to ensure that the aims, objectives and philosophy of the home, its services and The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 29 facilities, terms and conditions provide the individuals living at the home with choice, dignity, respect and enablement about their care, lifestyle, health and welfare. During this visit we spent a great deal of time discussing the reasons behind this requirement with the current manager, this, we were told is where they had focussed a great deal of their time and attention since our last visit. They told us that barriers had been broken down in respect of the unacceptable manner and approach of some of the staff members and that her priority had been to ensure staff were treating people living at the home as individuals, with dignity and respect. Examples were given to us about how people living at the home have been supported and enabled to make decisions, which affect their life and gave sound examples of how staff attitude had changed. During the site visit staff and those living at the home spoke highly about the management style of Mrs Mears. It was evident that whilst she was there she offered her staff clear direction and was motivational. Staff stated that she operates an open door policy. During our last visit to the home a requirement was made that reportable regulation 37 events/incidence must be recorded in care documentation to ensure an audit trail of the event. This requirement has been met, the manager of the home has ensured that we have been kept informed of incidents which have affected the wellbeing of people who live at the home, records within this area have been well maintained and clearly recorded to evidence what action has been taken, where possible, to prevent further reoccurrence and to ensure the safety and protection of people. During a previous key visit to the home a requirement was made that the Registered Person should ensure that all staff have the skills to deal with incidents of aggression and challenging behaviour and protocols for dealing with such episodes are documented. This requirement had been repeated, as the previous timescale of 1/3/08 had not been met. We saw within individual’s records that since our last visit, in particular the weekend before our key visit, that there had been incidents of aggression and challenging behaviour, which staff have had to respond to. We saw that appropriate action had been taken by staff in order to ensure the safety and protection of those involved and that protocols for dealing with such episodes had been documented. We also saw that the manager had contacted specialist services in order to support individuals with their emotional needs. We noted on training records that staff had not received training in dealing with potentially dangerous and difficult situations and this aspect of the requirement remains. When discussing the recent incident at the home with two staff members both told us that they had been well supported by the manager, however they also confirmed to us that they do need training in this specialist area, one staff member appeared to have been frightened by the experience. Training must be provided in order to equip staff with the skills needed to deal with incidents of aggression and The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 30 challenging behaviours, to ensure that people living at the home are supported appropriately and safely. During our last visit to the service a requirement was made that the registered person must ensure that there is effective management within the home. At this visit the manager informed us that they were leaving the home and that a new manager had been appointed. The new manager will be required to submit an application to us in order that they can be registered as the manager of the service. It is essential that the Provider and Manager must clarify roles and responsibilities, so that issues relating to Systems, Maintenance and Quality Assurance are auditable with clear lines of responsibility and accountability, this will ensure that action is taken when needed in a prompt and timely manner. During our last visit to the service a requirement was made that the Registered Person must 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. This was not able to be located at this visit and the manager had no knowledge of this. The requirement remains. (This requirement is repeated. Timescale of 31/3/08 not met). We accept that the home has some methods of monitoring quality such as review of peoples care, staff meetings, staff supervision and low levels of complaints, however, they do not form a plan about the continual improvement and development of the service. Prior to this inspection visit the home completed an annual quality assurance assessment (AQAA), which they submitted to us. This identified what the home feels they do well and sets out their plans for improvement over the next twelve months. It should be noted that the AQAA completed by the home was for services for older people, not young adults, therefore the form did not fully reflect the assessment of the service as required as there are a number of differing standards in respect of young adults and older people. This form must be completed correctly and resubmitted to us in order that we can fully evaluate the information provided. During this visit the manager and staff told us that regular staff meetings are held in order to look at ways of improving standards within the home and to discuss the needs of people living at the home. Within minutes of meetings we saw that these meeting had been occurring on a monthly basis since November 2008. Areas of discussion had included looking at ensuring positive outcomes for service users, protection of vulnerable adults and staff responsibility in this area, guidance of routines had been agreed and formulated taking into account the needs and wishes of people living at the home. These minutes of meetings showed us that staff had been challenged about their attitudes and these records evidenced a clear positive shift in staff approach and manner in supporting people living in the home in order that they are enabled and encouraged to make choices, which affect their life. The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 31 At a previous key visit a requirement was made that the registered person must establish a system for planning and identifying routine maintenance tasks and that this is evidenced through records. At this visit we saw that there are areas of the environment in need of improving. We also read recent reports, which had been completed by the Environmental Health Department and Health and Safety Executive. Within these reports recommendations were made that thermostatic valves should be fitted to hot water taps and asbestos checks should be undertaken within areas identified within the home and action should be taken as advised. It is required that the home must comply with the recommendations which have been set by these external regulatory bodies and take appropriate action as needed to ensure the health, safety and welfare for people who live and work at the home. During our last visit to the service a requirement was made that the registered person must ensure a system for Health and Safety checks of the environment is implemented regularly and that there are records to evidence this. This requirement had been repeated, as the previous timescale of 3/10/07 had not been met. In respect of the environment, we acknowledge that there have been some improvements in this area, however further action is required in order to evidence that health and safety checks of the environment are regularly implemented, as there were no records available to us to evidence that this is happening. A review of the fire logbook found that staff are receiving sufficient fire instruction and drills, maintenance and equipment checks are undertaken on a regular basis. We were concerned at this visit to find that during our visit in March 2008 it had been identified that there were bedroom doors, which were not closing properly. This situation was the same at this visit. One of the bedroom doors had a gap underneath it large enough to put a whole hand under it, another door on the top of the stairs would not close properly as the self closure was not working. Fire doors, which do not close properly, would be dangerous in the event of a fire occurring. At this visit we issued an immediate requirement that action must be taken to take adequate precautions against the risk of fire. When we returned to the home three days later we saw two different contractors on site who provided quotes for the work to be completed. At the time of writing this report the new manager contacted us to inform us that the work had been completed and the doors had been made safe in the event of a fire. We will be re visiting to check that action has been undertaken in this area. At this visit a further requirement was made that the home must consult with the fire authority and request a fire safety inspection of premises visit. The fire authority have not visited this home and inspected for a number of years, a visit from the fire authority would ensure that all measures needed for fire prevention and safety would be checked in full and guidance/advice given as may, or may not be required. We saw that the home had a well written fire risk assessment in place and saw that this covered how people living at the home would be supported to evacuate the building in the The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 32 event of a fire, however the area specific to individuals living in the home had not been reviewed since August 2008, it is recommended that this is reviewed and updated as required. During this visit we reviewed risk assessments in place in respect of household activities, we saw that a number of assessments were in place, such as use of the cooker and use of the laundry. These contained sufficient detail, however many other risk assessments such as use of cleaning equipment, use of the bath chair and other kitchen activities had not been reviewed for sometime, some since 2005. These must be reviewed, and updated where required in order to ensure that they are robust and contain correct information. Whilst reviewing the homes ‘environmental’ risk assessment we saw recorded that water temperatures are monitored and controlled by the home to ‘acceptable levels’, within the existing precautions it states that monitoring of all temperatures is undertaken on a monthly basis and that water temperature charts are kept up to date and accurate. When we asked to see these records we were informed that these do not exist. In order to ensure that hot water temperatures for people living in the home are safe it is required that the home maintain a record of checks to evidence that this area is monitored. When reviewing records for people who live at the home we noted that ‘residents property registers’ had not been reviewed and saw that the information contained within them was incorrect and out of date. These documents must be reviewed and updated in order that clear, audited information is maintained of people’s valuables and property. A member of staff assisted us when we randomly checked monies being held for safekeeping at the home. We reviewed the monies and records for four people and found that records corresponded with money held and spent. We saw that receipts are obtained to evidence purchases made by individuals, however receipts are not obtained from the chiropodist. It is required that receipts for this service are obtained in order to evidence that this service has been provided and at what cost. This key visit did not focus on the financial viability of the home. There was no evidence that the financial viability of the service was threatened in any way. An up to date insurance certificate was on display along with The Retreat’s registration certificate The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc Version 5.2 Page 33 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 2 2 X 3 X 4 2 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 1 25 3 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 1 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 1 X 2 X 2 1 X Version 5.2 Page 34 The Retreat, Quedgeley DS0000060002.V374946.R01.S.doc 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 Requirement The Statement of Purpose and Service Users Guide when updated must: Reflect the changes in the home. The status/plans for the swimming pool area. Be available in a variety of formats suitable for individuals who may reside at the home. This is to ensure that people are provided with accurate information about the home. A copy must be sent to the Care Quality Commission on completion. The Registered Person must 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 not met) In particular, the Registered Person must ensure that all Person Centred Plans: Fully involve the service user. Are clear and concise and jargon DS0000060002.V374946.R01.S.doc Timescale for action 31/05/09 2. YA6 15 30/09/09 The Retreat, Quedgeley Version 5.2 Page 35 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. 3. YA42 23 (5) The Registered Person must comply with the reports from the Health and Safety Executive and environmental Health. This is to ensure the protection and safety for people living and working at the home. The Registered Person must make the complaint/concerns procedure available in a variety of formats suitable for individuals who live at the home. This is to enable people to make a complaint who may have communication difficulties. The Environmental issues identified in the body of the report under Environment must be addressed. This is to ensure the protection and safety for people living and working at the home. 6. YA24 23(o) & 13(4a) The Registered Person must address the Health and Safety issues relating to the unused swimming pool area. This is to ensure the protection and safety for people living and working at the home. 7. YA30 23(d) & 13(3) The Registered Person must address the infection control issues relating to improving odour control within all parts of the home. DS0000060002.V374946.R01.S.doc 30/06/09 4. YA22 22.3 30/06/09 5. YA24 23(2b & o) 30/06/09 30/06/09 31/05/09 The Retreat, Quedgeley Version 5.2 Page 36 This is to provide a hygienic, pleasant environment for people to live in. 8. YA32 18(1a) The Registered Person shall ensure that all staff have the skills to deal with incidents of aggression and challenging behaviour and protocols for dealing with such episodes are documented. (This requirement is repeated. Timescale of 1/3/08 not met) This is to ensure that people in the home are supported in a safe and appropriate manner. 9. YA37 12 The Registered Person must ensure: There is effective management within the home. The Provider and Manager must clarify roles and responsibilities, so that issues relating to Systems, Maintenance and Quality Assurance are auditable with clear lines of responsibility and accountability. The Registered Person must establish a system for planning and identifying routine maintenance tasks and that this is evidenced through records. This is to demonstrate that a safe, well maintained environment is provided for people living at the home. 11. YA42 13(4a) The Registered Person must ensure a system for Health and Safety checks of the environment is implemented regularly and that there are records to evidence this. (This requirement is repeated. DS0000060002.V374946.R01.S.doc 30/09/09 30/08/09 10. YA42 23(2b) 30/06/09 30/06/09 The Retreat, Quedgeley Version 5.2 Page 37 Timescale of 3/10/07 not met). This is to demonstrate that a safe, well maintained environment is provided for people living at the home. 12. YA39 24 (1-3) The Registered Person must 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. (This requirement is repeated. Timescale of 31/3/08 not met) The Registered Person must ensure that property registers are in place for all, that those in place are reviewed and updated in order to ensure that the information contained within them is correct. To ensure an audit of peoples valuables are maintained. The Registered Person must consult with the fire authority in order to ensure the safety of those living and working at the home should a fire occur. The Registered person must take adequate precautions against the risk of fire: This was an immediate requirement that attention must be given to those fire doors deemed to be unsafe. Action must be taken to protect people and keep them safe should a fire occur. The Registered Person must ensure that the fire risk assessment is updated in order that it contains accurate evacuation information for those who live and work in the home. DS0000060002.V374946.R01.S.doc 30/07/09 13. YA41 17(2) 30/06/09 14. YA42 23 (4) 30/05/09 15. YA42 23(2) b 23(4) a 24/03/09 16. YA42 23 (4) 30/05/09 The Retreat, Quedgeley Version 5.2 Page 38 17. YA42 13 (4) 18. YA5 4(1) (c) This is in order that accurate information is in place about the evacuation support for people living at the home. The Registered Person must ensure that generic household risk assessments are reviewed. This is to ensure that potential risks are evaluated and areas of concern are made safe. The Proprietor needs to ensure that the homes’ contract contains all the required details and is compliant with the Office of Fair Trading Guidance. 30/05/09 30/06/09 19. YA6 12 (4) 20. 21. YA42 YA41 13 (4) a 13 (6) Consideration should be given to 24/03/09 the use of language within individual’s daily records. To demonstrate that people living at the home are being treated with dignity and respect. Records of hot water 30/03/09 temperature monitoring must be maintained by the home. Receipts should be obtained for 30/03/09 chiropody in order to evidence that services have been provided. 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. Refer to Standard YA22 YA24 Good Practice Recommendations The homes complaints procedure should be updated in order that correct information is provided for people about the address of The Care Quality Commission. Two of the bedrooms were identified as being fairly small and these should be checked to see whether they are under the minimum size requirements and if so this should be recorded in the home’s Statement of Purpose. DS0000060002.V374946.R01.S.doc Version 5.2 Page 39 The Retreat, Quedgeley Care Quality Commission South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: 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. 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