Inspection on 31/03/08 for The Retreat, Quedgeley

This inspection was carried out on 31st March 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 19 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 24/03/09

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 09/07/2008.

CARE HOME ADULTS 18-65 The Retreat 116 Bristol Road Quedgeley Gloucester Glos GL2 4NA Lead Inspector Mrs Helen James & Mr Simon Massey Unannounced Inspection 31st March 2008 09:30 The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 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.V356138.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 6th July 2007 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 DS0000060002.V356138.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 1 star. This means the people who use this service experience adequate quality outcomes. This Key Unannounced inspection took place over nine hours on one day in March 2008 and was completed by two inspectors. All Key Standards for Adults were assessed on this occasion. There have been major changes in the home since concerns about poor care practices were raised with the Commission last year. As a consequence there has been a change of Manager and some changes in the staff team. The new Manager has made application to the Commission (CSCI) and his application is being processed. Time during the inspection was spent speaking with six people living at the home all of whom were able to converse/communicate with the inspectors fairly well, the care staff, the Manager and Deputy Manager. There were no visitors seen during the inspection. Information was also gained via observation around the home. We observed care and assistance given to people and listened to the conversation and interactions between care staff, the Manager and people living at the home. We spent time cross-referencing information about the care, welfare and lifestyle of individuals gained from talking to staff and talking to and observing people living at the home. A range of records were examined to include care documentation, incidents/accidents, staff files, training records, rotas, quality assurance documentation and health and safety systems. A tour of the environment was also made. The pre-inspection Annual Quality Assurance Assessment (AQAA) record was completed by the Manager and forwarded to the Commission prior to the inspection. This contained details of the challenges facing the Manager and the objectives that he had for the home, but some of this lacked the detail of how it was to be achieved and no supplementary documents were received with the AQAA. Comment cards were sent to the service for distribution prior to the inspection, four relatives/representatives of people living at the home responded, five staff, and three health care professionals who visit the home returned these, as did five people who live at the home. What the service does well: The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 6 The service maintains contact with families and advocates well. There is also good access and assistance from staff for people to integrate into the local community. People are encouraged to go out if they are able to, no unnecessary restrictions appear to be placed on people at this time. There was evidence that appropriate medical reviews and healthcare appointments are maintained or requested. What has improved since the last inspection? What they could do better: Person centred records examined, lacked clarity, were written in a jargonistic manner and did not provide clear instruction on how to care for people. Care documentation must inform and underpin care practice within the home and it does not at the present time. The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 7 Policies and procedures, and specifically risk assessments need to be developed to define clearly what the need is for the individual and how this is to be managed, for example around independent travel in the community, residents’ involvement in running of the home and their personal safety. While it is positive to maintain as much independence/enablement as possible, consideration must be given to health and safety issues and the advice of outside professionals when they are involved in the care of individuals must also be taken into account. An assessment needs to be completed that identifies risks and provides guidance to staff on all aspects of moving and handling, cleanliness and hygiene and other associated risks. Occupational activities for some people need to be improved to ensure quality of life for everyone living in the home. The Manager and Registered Provider must continue to address the attitudes and care practices of some staff towards people living at the home through effective supervision and appraisal systems in the home. 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 residents. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 8 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.V356138.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service aims to carry out a comprehensive assessment of any prospective new resident and document their needs and aspirations to ensure these are met through person centred plans. EVIDENCE: The AQAA states that since November 2007 the Manager has put in place a new admission structure, although no new admissions have been made to date. We are unable to test this standard but the manager stated that the plan is to ensure all information is available prior to admission and that trial visits are made to ensure the service can meet the needs of the individual and that it is costed appropriately. The statement of purpose and service users guide are being updated and are available in the home. These must be made available in a variety of formats suitable for individuals who may reside at the home. The updated version must reflect the changes in the home, the status/plans for the swimming pool and also state room sizes. When these have been completed a copy must be sent to the Commission. The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 10 The home provides a contract that includes room number, fees, terms and conditions. The Home’s Website is being updated to describe accurately the services supplied by the home. The Manager is changing the approach in the home to ensure much more involvement of the resident; their families/representatives and advocates. This was evidenced by records of peoples’ individual care reviews and was witnessed by inspectors on the day of inspection. The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments seen did not include specific detail and direction regarding the needs of individual people. As a consequence, staff do not have sufficient information to ensure that people are treated in a consistent manner that enhances their independence and reduces risks. EVIDENCE: Although the Manager had stated in the AQAA that clearer care planning and risk assessments were something the home did well, we found that plans examined were not particularly individually focused and personal needs, aspirations and goals were not particularly well written Previous inspections concluded that detailed Person Centred Plans were not available for everyone, contained limited information and risk assessments were not in place. Those that were in place were not up to date, regularly used or person centred. Language used in them was inappropriate and information was either missing or not written in the correct place. The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 12 During this inspection four personal care plan (PCP’S) files were examined and of these all were lacking in clear concise information relating to guidance for staff on how people were to be assisted /cared for and also what the objectives and goals for individuals were. This was both in terms of short, medium and long-term goals. It was not clear what the involvement of the service users was in the developing of these plans. Some of the language and grammar is at times confusing and over complicated in places. Person Centred Plans should fully involve the service user and enable staff to turn documentation into practice and clearly identify the prioritised goals and objectives that staff should be aware of for the people concerned. How people are to be managed in relation to risk and individual’s circumstances is still not documented well. The risk assessments are difficult to follow in that they do not always provide clear outcomes or guidance. They also contain statements that would be better located in the care plans. Concerns about the risk assessments relating to independent travel and movement are contained in the Lifestyle Standards. Personal files also contain a form that has a list of “Strengths and Needs”, which is used as a quick reference guide for staff. These forms had no dates on them, were not signed and had no evidence of service user involvement. In all files examined there was evidence of written information that was difficult to understand and interpret for example: Area of need:- Communication (updated 28/11/07) GOAL:- For X to be supported and encouraged with all aspects of their communication skills, styles and preferences in the home and wider communities - attention needs to be paid to the fact that verbal communication is limited as is hearing impairment. WHEN WILL IT BE DONE: - As part of X’s communication plan and routines staff are employed to listen, assess need and provide appropriate or adapted forms of communicating. WHO: - All direct staff- communication comes in many forms words actually spoken only actually constitutes a very small percentage in life. Body language, gestural, tone, pitch, eye contact and body language all have the essential parts to play in individuals life. The home is in the process of introducing new care plans, assessments and risk assessments. With the recruitment of several new staff members the Commission acknowledges that there is a period of transition whilst the new systems are implemented and will monitor progress closely at subsequent inspections. The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 13 However, the sample of new documentation seen raised concerns for the inspectors because clear concise fundamental information was still lacking or written in a manner that could not be clearly understood. This was identified and discussed with the Manager and Deputy. Whilst accepting that much work is in progress and that key-workers are still getting to know people living at the home, basic care information must be available for everyone. There also needs to be greater clarity in the care planning system and the information that is being put into place to ensure it informs and underpins practices within the home. Interviews and conversations with staff demonstrated that awareness was being developed of individual needs and there was a commitment to improving choice and the quality of lifestyle. Increased ownership of the process by care staff is important if the people living at the home are to be more engaged in the planning of their care and support. Some people spoken to had some understanding of their care plans and that review meetings were held, but this appeared to be limited. Several of the personal files contain the person’s “preferred term of address”. However on several occasions during the inspection staff were heard referring to people living at the home using terms such as “dear”, “my darling” and “my love” instead of their name. This appeared inappropriate and staff should receive guidance on this. Some confidential recording in relation to the service users was located in the kitchen and this information needs to be stored securely. This included a staff message book and a behavioural analysis chart. The inspectors were informed about some planned changes to the office arrangements that will make the practical storing and accessing of documents easier for the staff team. The present office rooms are both very small, which means that staff generally complete written records in other parts of the home such as the living room and dining room. These changes should help practically and also help communication and discussion between staff members to be conducted in more appropriate confidential surroundings. The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15,16 & 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service now appear to participate in age, peer and culturally appropriate activities through engagement in social activities of their choice and liking but this could be improved by making more individual arrangements for people. Whilst this outcome group has been assessed as adequate, there are serious shortcomings identified around the assessment of risk for people accessing the community, either supervised or alone, which potentially places residents at risk. EVIDENCE: The home has not in the recent past been enabling people living within the service to maintain appropriate and fulfilling lives in and outside of the home. There has been an institutional approach towards individual’s privacy, dignity, promotion of wellbeing and independence within the home, although, since the The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 15 new Manager has been in post there seems to be a move to address this. People appear to now participate in age, peer and culturally appropriate activities through engagement in social activities of their choice and liking, although there is still scope for improvement. Staff explained how they are attempting to increase the range and frequency of activities undertaken by some people. Some people have limited regular daily activities at present, and some people spoken to could give few examples of things that they had done in the previous week or were planning to do. Staff recognise there is work to do in this area and there was evidence that individual keyworkers and Management were looking at various ways of increasing choices and encouraging some people to undertake more activities. Staff are now recording all activities in activity diaries and work is also being done to produce weekly individual timetables. Some people have regular weekly routines, attending day-centres and visiting relatives and some people expressed satisfaction with the variety in their lifestyle. However some people did say that at times there was not enough to do, either in the home during the day or in the evenings and at weekends. The television in the living room, which is the main communal area, is continually on all day, though there is the option of using the dining room. People who live at the home were seen helping with some cleaning chores and also undertaking some laundry tasks. The main meals for the day were both prepared by the staff team, and staff explained how they planned to increase the involvement of service users in this aspect of daily living. During examination of the environment it was noted that one room was painted pink but all the other 13 bedrooms in the house were painted a cream colour. This raised questions on how people make choices in relation to the decoration and furnishing of their own personal environment. People are supported to maintain regular contact with family and relatives, and these contacts are recorded in the daily files. Several people described how they accessed and used local facilities and amenities and how they had a good knowledge of the local area. A number of the people are able to access the community independently or with limited support. There are risk assessments in place in relation to this, both in the care plans and also in a folder for Environmental Risk Assessments. However, these assessments do not provide clarity on exactly how, when and where people can go and how long and where they are able to travel independently and what safe guards are in place. It is not entirely clear exactly who can go out unsupervised. Some people go out but only with certain other people. There is also no guidance on the numbers of staff required to support certain individuals or different combinations of individuals accessing the community. These assessments must provide clear guidance for staff who themselves gave The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 16 varying opinions about the independent ability of people living at the home and the protocols to be followed. The front door of the home is locked with a keypad but the rear doors are unlocked and during the time of the inspection the side gate of the home was permanently open, though it was said that this was generally shut and locked. The Manager stated, “that any service user could leave unsupervised and wander into the road”, but this is not reflected in the care plans or risk assessments for people in the home. This is a serious shortcoming. Staff explained how they are improving the diet and menu choices for the people at the home. Work is being done to provide more fresh produce and less processed food on the menu and to involve people who live at the home in identifying menu choices. Staff plan to provide more opportunities for people to be involved in food preparation and the domestic tasks around mealtimes. Menus showed that some choice is provided and people were generally pleased with the food. Several people said they would like the chance to do more cooking. Positive changes have been made to the accessing of food and drinks and individuals were pleased about this. People were observed entering the kitchen and making drinks and snacks. Evidence was also seen that some previously identified staff attitudes to mealtimes and food are being challenged and that food is no longer being used as a punishment or incentive in relation to behaviour management. The kitchen was well stocked with packaged and processed food at the time of the inspection but there was no fresh fruit and little fresh vegetables in evidence. However, it was explained by the staff on duty, that it was a shopping day and that fresh fruit would be purchased later in the day and this was now freely available to the people at the home. All food in the fridge was correctly stored and labelled. The Retreat DS0000060002.V356138.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care of individuals is based on individual need and the principles of respect, privacy and dignity. However, documentation underpinning this is lacking in clarity and information relating to how care is to be given / supported by staff and how the person requiring the care has been involved in this process. Poor practice regarding the moving of individuals could place certain residents at risk. EVIDENCE: The Manager in his action plan of the 30th November 2007 stated that medication requirements have been addressed and he reports that new controls are in place with regular auditing from the Manager. He also stated that all staff who deal with medication are all being re-assessed by the Manager and they have all received accredited training evidenced by certificates. The Manager reports that proper procedures for homely remedies have now been arranged, although these were not examined. A Medication The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 18 audit is in place now and appropriate storage is now available. Medication procedures were not examined at this inspection. The personal files contain information about the personal care that individuals require, though more detail could be provided on how this is to be delivered. Several people living at the home spoken to expressed satisfaction with this aspect of care. The files contain records of health appointments that have been supported and any advice and guidance is then written into the daily recording. There is lack of guidance in relation to managing one person who uses a wheelchair. There is no guidance in relation to transfers from the wheelchair and in respect of other moving and handling manoeuvres that have to be completed. There was also some confusion as to the appropriateness and safety of the individual when travelling around the home on the floor. One staff member was observed undertaking a transfer from a vehicle to the wheelchair, which appeared to be unsafe. The wheelchair’s seat belt was not done up and the wheelchair was pulled the wrong way up the ramp at the rear of the home. Failure to ensure that safe handling practice is documented and carried out by staff places both staff and residents at risk of injury. An assessment needs to be completed that identifies risks and provides guidance to staff on all aspects of moving and handling, taking into account advice from external professionals such as an Occupational Therapist. Training and guidance in this area is therefore required. Staff are actively encouraging and supporting people to allow choice in what they do on a daily basis, but this has not been underpinned by good records of what is being done, when and how. Aids and adaptations have been provided but these are not always used appropriately and care records are not written to demonstrate to care staff what they should be doing when providing care. Key working has been implemented and staff know what is expected of them within this keyworking role. The Manager reports in the AQAA that these things all still need improvement. The Retreat DS0000060002.V356138.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and are confident in the knowledge that any concerns they may express will be listened to and acted upon. Systems have improved in the home to ensure that people are safeguarded from possible harm or abuse but further work is required to ensure this is sustained. EVIDENCE: In the last six months there have been a series of anonymous complaints / concerns relating to practices, cleanliness and staffing at the home and these have been examined through a series of unannounced random inspections and discussed with the Manager. A number of breaches of regulations were identified as a result. There are monthly client meetings that provide another forum for people to express their concerns. These are well attended and minutes of these meetings are displayed in the home although they need to be available in a variety of formats appropriate for those people living in the home. The complaints policy and procedure is displayed in the home. The manager should consider how to produce the complaint procedure in a format appropriate to the needs of people who are unable to read, for instance using symbol or photographs. A complaint, concern, compliments record is now kept in the home. The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 20 From talking with people living at the home and examining questionnaires from relatives and representatives they all report that since the Manager has been in post they feel they are listened to and action is taken when they have concerns. Both residents at the home and relatives feel able to approach the Manager or Deputy about anything and feel that it is acted upon, although two representatives feel it is too early to judge and that it is important to see whether this approach is sustained. Staff are now being trained to understand what is expected of them within the confines of protection of vulnerable people and training has been arranged for all care staff in Protection of Vulnerable People (POVA) and the Mental Capacity Act, which is ongoing at the present time. The Retreat DS0000060002.V356138.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The physical environment is in need of a programme of decoration, cleaning and maintenance that is sufficiently robust to ensure a comfortable, pleasant and above all safe environment for the people who live there. EVIDENCE: An inspection of the environment was carried out. It was stated by the Manager that a change had been made to method of cleaning of the home with an attempt being made to involve the people living at the home in cleaning, rather than the staff completing these tasks on their own. This is a positive development but it was observed that various parts of the home were not clean, including corridors and some of the bedrooms and toilets. Debris of food, crisps, talcum powder, general dirt and dust was observed that gave the appearance that areas had not been cleaned for a period of time. Various parts of the home also require decorating and the following maintenance issue were identified. The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 22 • • • • • • • • • • • • • • • • • 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. 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. 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. Bedroom 11 has damage around the skirting board and also a door that does not close properly. 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. 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. There was a folded put-u-up bed under the stairs with a pile of bedding stacked on top, which presents a fire hazard. 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. 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. In the adjacent shower room there again was no soap and also no plug in the sink. 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. Bedroom 2 has a door that would not close properly. 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. In one bedroom at the end of the corridor the Inspectors found a stereo purchased by the individual that had been plugged into the shaving socket and was also located directly in front of the washbasin. The Manager removed this on safety grounds during the inspection. In bedroom 4 the light switch in the toilet did not work properly and the shower door was damaged and needed repair. The bedroom on the top floor had a door that would not close properly. Two of the bedrooms were identified as being fairly small and these should be checked to see whether they are under the minimum size DS0000060002.V356138.R01.S.doc Version 5.2 Page 23 The Retreat requirements and if so this should be recorded in the home’s Statement of Purpose. The above list includes a number of doors that do not close properly, which compromises fire safety. Under the Lifestyles section, comment has been made about the security of the building, particularly at the rear where back doors were left unlocked which could present a hazard to residents. The house has a large rear garden, which contains a swimming pool. However this is currently not in operation, which has meant that the large lawned area is partitioned off, meaning that a large part of the ground is currently inaccessible to the people living at the home. This partition consists of sheets of wood that have been placed in the gaps in the wall to the swimming pool area. The wall is in need of repair. The height of the wall and wooden sheets are only about 3 foot high and the patio area around the pool presents a serious health and safety risk, as the pool is still full of water and covered with a tarpaulin. Many of the paving slabs have lifted and the pegs locating the tarpaulin present a tripping hazard. If so inclined, it would be relatively easy for people to access this area and action should be taken to provide greater protection and safety here. To the side of the laundry room are located the rubbish bins, one of which is designated for clinical waste. At the time of the Inspection there was also an additional small bin without a lid, containing clinical waste in untied plastic sacks. At the rear of the property is a parking and patio area and this was generally untidy and in need of attention. The front of the house has a damaged drainpipe to the right of the building and number of loose wires. Further down the side of the house an overflow pipe was leaking from the roof, forming a large puddle in the adjoining playing field. There is a need to establish a system for planning and identifying routine maintenance tasks around the home and to have documented records to evidence this. It is also essential that a systematic health and safety check of the environment is implemented on regular basis and that this is evidenced through records. Staff spoken with confirmed they had received infection control training and records confirmed this. There was evidence that staff are provided with personal protective equipment that is accessible throughout the home, although in several communal areas there was a lack of single use soap and hand towels which must be addressed. The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team now have greater access to accredited training programmes to ensure they have the knowledge and skills to deliver the support and care that individuals who live at the home require. The staff team is sufficient in numbers to ensure that they are able to provide care for the diverse needs of people living at the home. People are not fully protected by the recruitment practice now implemented at the home it needs to be fully robust. EVIDENCE: There has been a significant turnover of staff in recent months, with a new Manager and care staff being employed. Staff spoken to said they thought the team was developing in the right direction and that there were good levels of support available. The introduction of new ideas and the changing of certain longstanding practices has been challenging for some staff but they were able to demonstrate an understanding of the direction and changes that the new management are attempting to implement. The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 25 All staff have been receiving regular formal supervision and some documented evidence was seen of this during the inspection. Feedback has been provided through these sessions as well as at team meetings and through the communication book regarding issues that the management wish to progress. Recruitment practices within the home have improved greatly and all the required documentation was in place for most newly recruited staff. But two issues were identified in two employment files: one had a reference from a member of family and one had a gap in the employment history, these were discussed with the Manager and Deputy and will be addressed. There was evidence that residents are getting involved in this process. Where one new member of staff had started working but was still waiting for a full CRB clearance there was a POVA First check on file and a written risk assessment for him to work alongside someone else at all times until the CRB arrived. The AQAA and Manager state that all new staff complete a comprehensive induction and foundation pack and that he will ensure that all staff are given the General Social Care Councils code of conduct. People living at the service made several positive comments about the staff team, saying they were “nice” and “helpful” and also that we “all get on well now”. Two people spoken to say the staff respected their privacy and that “they liked going out with them to places”. There appeared to be a reasonably relaxed atmosphere within the home, with staff and service users interacting throughout the day in a friendly manner. There was evidence via the AQAA, records and through talking with staff that a considerable amount of training was now being planned and attended. It is imperative that this continues to ensure that all staff continue to receive training appropriate to the needs of individuals at the home and that mandatory training is continually updated. This has been a failing of the home in the past. The Manager needs to monitor through supervision of staff that what is learnt through training is translated into appropriate practice. The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst a new manager has been appointed and there are early signs of changes in the culture of care in the home, there is still a considerable amount of progress required to ensure the home is effectively run with the best interest of residents at its heart. The management of the home cannot yet demonstrate that systems are fully in place to ensure the health, safety and welfare of people living and working at the home. EVIDENCE: The Manager has applied to the Commission for registration and his application is being processed. The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 27 In the AQAA the Manager states that there are still many areas where he wishes to make changes and improvements. There have been several staffing changes over recent months and the Manager and Deputy are taking steps to try and provide consistent practice and team working. Staff have been provided with regular supervision and there was evidence that poor practice is being challenged and direction provided. We were concerned about some of the entries from the management in the staff message book; some were of a critical nature that would be better dealt with confidentially with the individual concerned rather than in an open staff forum and the tone of some entries seemed slightly sarcastic or aggressive. The home has a new Deputy as well as a new Manager and staff were generally positive about the support they receive, though some felt that there was progress still to be made in developing the team processes and acceptance of new ways of working. The Manager is now more aware of what incidents and events require reporting under the Regulation 37 notice and the Commission is now receiving these. But there is still a gap in recording these significant events in the daily care records for individuals as found with one serious event that occurred and was cross referenced during the inspection. The Manager must address this and ensure that there are auditing systems within the home that can detect these failings. The home has a Fire Risk Assessment in place and all routine fire testing and evacuations have been completed and recorded. The current servicing certificate was not seen as the Manager did not have access to this and he reported it was the Proprietors responsibility. This was sent to CSCI following the inspection. There was good information recorded about the evacuation procedure and which service users would be at risk. Issues identified under the Environment section highlighted potentially unsafe factors which should have been picked up through regular health and safety audits of the building, such as security and fire safety. It would be better practice for a system to be in place which would routinely check the whole building for potential hazards or maintenance issues and that this is documented. Quality Assurance systems and processes were not looked at during this inspection, as they need to be developed and implemented with the new Manager and Provider. The Manager and Provider need to evidence that they are reviewing all aspects of performance through self-review and consultations seeking the views of residents, relatives and stakeholders. The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 2 X X 2 X The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? Yes 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 Regulation YA1 4 Requirement Timescale for action 30/06/08 2. YA6 15 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. A copy must be sent to the CSCI on completion. The Registered Person must 30/06/08 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 free. DS0000060002.V356138.R01.S.doc Version 5.2 The Retreat Page 30 3. YA6 15 & Schedule 3 4. YA6 15 5. YA16 13(4c) 6. YA38 12 Clearly identify the prioritised goals and objectives that staff should be aware of for the people concerned. • Inform and underpin practices within the home 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. (This requirement is repeated. Timescale of 3/10/07 not met) 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. (This requirement is repeated. Timescale of 3/10/07 not met) 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. The Registered Person shall ensure that the culture of the care home is conducted to ensure that the aims, objectives and philosophy of the home, its services and facilities, terms and conditions provide the individuals living at the home with choice, dignity, respect and enablement about their care, lifestyle, health and welfare. (This requirement is repeated. Timescale of DS0000060002.V356138.R01.S.doc • 30/06/08 30/06/08 30/06/08 30/09/08 The Retreat Version 5.2 Page 31 1/3/08 not met) 7. YA22 22.3 The Registered Person must make the complaint/concerns procedure available in a variety of formats suitable for individuals who live at the home. Reportable Regulation 37 events/incidence must be recorded in care documentation to ensure an audit trail of the event. The Environmental issues identified in the body of the report under Environment must be addressed. The Registered Person must address the Health and Safety issues relating to the unused swimming pool area. The Registered Person must address the infection control issues relating to: • Cleanliness in the home. • Ensuring hand washing and drying facilities are available in all parts of the home. The Registered Person must ensure that robust recruitment procedures are followed, particularly with regard to obtaining references and a full employment history The Registered Person shall develop a documented training and development plan for all the staff at the home. The Registered Person shall 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. The Registered Person shall ensure that all staff have the skills to deal with incidents of DS0000060002.V356138.R01.S.doc 30/06/08 8. YA23 42.7 30/05/08 9. YA24 23(2b & o) 30/06/08 10. YA24 23(o) & 13(4a) 23(d) & 13(3) 30/05/08 11. YA30 30/05/08 12. YA34 19 Schedule 2 31/03/08 13. YA35 18(c) 30/06/08 14. YA32 18 01/05/08 15. YA32 18(1a) 30/06/08 The Retreat Version 5.2 Page 32 16. YA37 12 17. YA42 23(2b) 18. YA42 13(4a) 19. YA39 24 (1-3) aggression and challenging behaviour and protocols for dealing with such episodes are documented. (This requirement is repeated. Timescale of 1/3/08 not met) The Registered Persons 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. 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. Timescale of 3/10/07 not met) 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) 30/05/08 30/06/08 30/06/08 30/09/08 The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 33 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. Refer to Standard YA5 YA10 YA24 Good Practice Recommendations The Proprietor needs to ensure that the homes’ contract contains all the required details and is compliant with the Office of Fair Trading Guidance. Ensure confidential information is kept secure. 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. The Retreat DS0000060002.V356138.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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