Inspection on 06/07/07 for The Retreat, Quedgeley

This inspection was carried out on 6th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 7 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 31/03/08

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 Key Unannounced Inspection 6th August 2007 10:00 The Retreat DS0000060002.V342548.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.V342548.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.V342548.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 Mrs Lisa Alicia Kritina Garvie 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.V342548.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2006 Brief Description of the Service: The Retreat is a large detached property in Quedgeley providing accommodation for up to fourteen adults with learning disabilities. The home is staffed at all times. Service users are accommodated in single rooms, some with ensuite facilities. The home is located close to a supermarket, post office and other facilities and is on a bus route. Gloucester city centre is approximately three miles away. A large lounge and a separate dining room are provided on the ground floor. There is a substantial garden, which includes an outdoor swimming pool. The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This Key unannounced inspection took place in August 2007 and included a site visit to the home. Thirty-one Care Standards for Younger Adults were assessed on this occasion. Of these four exceeded the standard, twenty-four met the standard and three almost met the standard. Time during the inspection was spent speaking with the Manager, proprietor, staff and people at the home. A range of records were examined including care plans, medication records, staff files and training information as well as health and safety systems and the environment. The pre-inspection Annual Quality Assurance Assessment (AQAA) record was provided to the Commission prior to the inspection. Comment cards were sent to the service for distribution following the inspection. Five people living at the home returned comment cards and four surveys were returned from staff. Four comment cards were received from relatives/visitors of people living at the home. All were very positive about the care provided and the style of management of the home. All felt that the manager and staff were approachable and that the people living at the home were happy and well cared for. There were no visitors to the home during the inspection. What the service does well: The inspector was fortunate to inspect the home when all the people were at home as day centres, work placements etc were closed due to the recent flooding and lack of mains drinking water. People living at the home were smiling and happy, although some were anxious due to the interim changes in their daily routine, but this was being well managed by staff. Some people were engaging in ‘day-to-day’ tasks within the home, such as dusting, hoovering, shopping and several were assisting in the kitchen under staff instruction. Two people went out with the proprietor to an office supplier and several went out to the local superstore to do the food shopping. They all appeared and said they enjoyed doing these tasks and liked being involved with the daily routine of the home. Several chose not to go out and were quite happy doing their own thing in the home, sitting, reading, listening to music or watching the television. Two people living at the home had been out on their own on the bus into town to buy things, this was part of their care in terms of independence and enablement. The interactions and care observed during the visit were kind, considerate and appropriate. Difficult situations were well managed and dealt with in a consistent manner. Whilst staff were busy there was a calm and homely atmosphere. The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 6 People were able to speak to the inspector during the inspection and were complimentary about the care that was given and the friendly and supportive manner of the staff employed at the home. Stating that “they were very happy at the home’, ‘they didn’t want to move anywhere else’ and that the staff were helpful and gave good support and assistance when you needed it”, “they felt they were treated with respect and they were treated as individuals and facilitated to do things independently where they were able to. One gentleman discussed with the inspector the fact that he was able to practice his religion without discrimination. Two women spoken with were able to go out into town and the local shops independently and they really enjoyed doing this and would often go to the shop to get things for the home. One really enjoyed the fact that she was allowed to help with the cooking with supervision and on the inspection day she was in the kitchen cooking the tea, which was macaroni cheese; it looked and smelt good. One man spoken with was anxious because he couldn’t go to the farm and he really enjoyed going there and he found it difficult to deal with changes in his routine. He was managed well by staff, given reassurance and encouragement during the day. There was one grumble about not being able to have a lighter and cigarettes but these were being held by the home for health and safety reasons and the person had access to them on request, but this had no impact on the outcomes for people living at the home. What has improved since the last inspection? What they could do better: Staff must have access to training on the safeguarding of adults and the Mental Capacity Act to increase their awareness of these issues. The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 7 There are some environmental issues that require addressing to ensure peoples safety within the home and the need for implementation of documentation to evidence the safety checks informally in place. There is also the need to enhance the quality systems within the home; the Manager needs to seek and evidence the views of its community stakeholders to give a holistic assessment of the quality of service provided to people by the home and draw together all the audits within the home into a report framework. From this an annual Quality Assurance report needs to be produced and supplied to the Commission to evidence the review of the effectiveness of the quality systems in the home and it must include residents, relatives and stakeholders’ views and future developments for the home. 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.V342548.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.V342548.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): 1, 2, 4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that people who use the service are fully assessed prior to admission and on admission, to ensure that all their specific care needs can be met by the Home. The statement of terms and conditions and contract provides people with information about the service they will receive from the home. EVIDENCE: All prospective new people would be encouraged to visit the home with their relative/social worker/ friends prior to admission, this familiarises them with the home, its facilities and the staff. All people planning to live at the home have their care requirements fully assessed before admission to ensure that the Home is able to meet their needs and they are encouraged to have short trial periods at the home. There has been one new admission to the home since the last inspection. People had contracts (a sample were seen) but it tends to be Social Services /the relative or representative who deal with this, due to the fact that many are unable to deal with this themselves. The homes’ contract must contain all the required details and be compliant with the Office of Fair Trading Guidance it is recommended that the Manager ensures this. The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 10 The Statement of Purpose and the Service Users Guide are located in foyer of home, displayed and accessible. The Service User Guide is now available in a pictorial format for those with communication needs. The Retreat DS0000060002.V342548.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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are treated with respect and dignity and facilitated by staff to live as fulfilling and independent a life as possible within their own limitations. The systems within the home involve individuals and their families, ensuring that there is a clear understanding of the person centred approach to care within the home. EVIDENCE: Individuals’ records are accurate, secure and confidential. Comprehensive information is maintained for people living at the home. These are being constantly monitored, reviewed and updated monthly or more frequently if required. Support plans are discussed with each individual person and where possible signatory evidence on plans is being sought to demonstrate individual’s involvement in the preparation of these and their agreement. It was evident from the daily records and observation that staff adhere to support plans, timetables and risk assessments and facilitate the choice of individuals. Any The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 12 restrictions to choice or freedom are recorded on people’s files. Some of the risk assessments in place were examined and demonstrated enablement within a risk framework. These are signed and regularly reviewed. One risk assessment plan was not in place and this was discussed with the Manager. Through discussion with the manager and observations at the home it was evident that personal autonomy and choice are promoted as fully as possible and people spoken with confirmed this. People living at the home were spoken too and addressed properly and interactions were appropriate. People living at the home have choice about their daily routine and are consulted about all aspects of life at the home, where possible, using a variety of communication tools and monthly house minuted meetings. People living at the home have opportunities to help with the day-to-day running of the home by assisting in preparation of meals, washing up, clearing up, cleaning their room, dusting and shopping to list a few. They are encouraged to use their full potential and learn new skills. Six people living at the home are going to do a First Aid course. The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 13 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): 11, 12, 13, 15, 16 & 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living at the home participate in age, peer and culturally appropriate activities through engagement in social and recreational activities of their choice and liking within the local community. EVIDENCE: People living at the home have individualised programmes of daytime activities during the week. The Manager is in the process of implementing activity/social event files for individuals where entries are made about the activities they have participated in and with whom, giving a valuable insight into the diversity of activities that they engage in. It also will demonstrate that not everyone is doing the same thing and also demonstrates that they are part of the wider Community. The Manager has undertaken a skills audit of all clients to enable activities to be focused and structured for individuals. Two members of staff are to become joint activity organisers within the home to facilitate this. The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 14 Five people went on holiday this year and when people go on holiday a travel diary is written, this was seen at the visit. Only five wanted to go on holiday this summer the others wanted days out rather than to go away for a week, several people spoken with confirmed this. The inspector was fortunate to inspect the home when all the people were at home as day centres, work placements etc were closed due to the recent flooding and lack of mains drinking water. People living at the home were smiling and happy, although some were anxious due to the interim changes in their daily routine, but this was being well managed by staff. Some people were engaging in ‘day-to-day’ tasks within the home, such as dusting, hovering, shopping and several were assisting in the kitchen under staff instruction. Two people went out with the proprietor to an office supplier and several went out to the local superstore to do the food shopping. They all appeared and said they enjoyed doing these tasks and liked being involved with the daily routine of the home. Several chose not to go out and were quite happy doing their own thing in the home, sitting, reading, listening to music or watching the television. Two people living at the home had been out on their own on the bus into town to buy things, this was part of their care in terms of independence and enablement. The interactions and care observed during the visit was kind, appropriate and considerate. Individuals are encouraged to eat a healthy balanced diet and educating the individuals about the importance of a healthy diet is ongoing. This is done through involvement of individuals in shopping and preparation of the meals. Weight monitoring for loss and gain is undertaken monthly and recorded. Appropriate action is taken to address any issues raised that may impact on the health of the individual. All the required checks are in place in the kitchen and staff maintain comprehensive records in line with ‘Safer Food, Safer Business’ guidelines and a recent Environmental Health inspection awarded a ‘scores on the doors’ ‘5’ star rating. Training records were seen for all staff for food safety and food hygiene. Menus were supplied prior to the inspection. The Manager audits the catering provision. One person was being supported in the kitchen to cook the tea for everyone and it smelt and looked delicious, this happens regularly as the person involved is hoping to go back into the community and live in supported living accommodation. People living at the home are given choice in everything they do and are consulted about what they want to do within the restrictions of their ability and safety. Assistance and supervision for all activities is available at all times and where extra staff is needed this is made available. During the inspection the inspector observed the following ;-It was a warm, sunny day during the visit and several of the people living at the home went The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 15 and sat on seats on the patio area, the inspector observed the proprietor going and sitting with them all. They all had tea and cake and sat for quite a long time prior to tea. The people at the home looked very comfortable and at ease, laughing and chatting with him as though this was something that occurred frequently and wasn’t unusual. (The manager reported that he often sat talking with them around the home, in the lounge or garden). The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. The personal needs of people living at the home are met and they are based on the principles of respect, dignity and privacy. Healthcare need are met through good multi disciplinary working and People are protected by the home’s policies and procedures for dealing with medicines; although some refinements are needed to make them more specific to support and inform practice within the home. EVIDENCE: Comprehensive information is maintained for people living at the home. This is being regularly monitored, reviewed and updated. Three care records were examined for three people, all were observed during the inspection and spoken with albeit some could give limited responses. The support records contained all the required documentation and were clear in how the individuals were to be managed regarding their care. Support plans are discussed with the each individual person and their next of kin (where necessary) and signatory evidence on care plan and reviews is now being sought to demonstrate individuals’/next of kin involvement in the preparation of these plans. The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 17 People living at the home were observed spoken too with respect and addressed properly and all interactions were appropriate. It was evident from daily records and observation that staff adhere to support plans and risk assessments. Risk assessments, monthly weight and personal background information is recorded for each person. A photograph of people should be kept with the care file to aid identification, but not all had these. Daily recording was observed to be appropriate and informative. The support plans are reviewed at least once a month or more frequently if peoples care needs change. The inspector read support records for three people who were casetracked one of whom was new to the home; these people were spoken with and observed during the inspection. The records confirmed the assistance and care that the people required with one exception where this information was not in the file. The specific risk assessments and care plans relating to’ behaviour management’ were not on the care file when examined, these were on the managers computer, she explained that they had been changing continually and they had had to alter them. The inspector advised that it should be on file even if they were hand altered until a final management programme had been achieved. These were put on file during the inspection. There is the requirement for some minor amendments to care plans: • Where there are specific measures in place for dealing with specific behaviour these must be on the care records so that all staff are aware of how they are to be dealt with and it is not dependant on word of mouth. • A recent photo must be available on all care files. • The Manager must regularly audit care files and care plans to ensure that the correct information is recorded, dated, signed and that there is consistency of recording in the home. All documentation is kept securely in the home and is readily accessible to all the staff responsible for providing care. Any restrictions to choice or freedom are recorded on people’s files. Through discussion with the Manager and observations at the home it was evident that personal autonomy and choice are promoted as fully as possible. All medical and healthcare visits and checks are clearly recorded and comply with the health checks required by the individual. All equipment needed for peoples’ health care is supplied appropriately by the Community Nursing services or the GP. People are referred to the Community Learning Disabilities Team and to the appropriate health and welfare professionals at their request or when it is necessary. The homes medication system has been changed and a monitored dosage system is now used to promote safety in medication dispensing. The supplier does a monthly audit at the home. All staff involved in dispensing are ASSET The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 18 trained. The Manager explained the procedures and processes in place. No one is able to self medicate. Two amendments need to be made: • There needs to be a list of staff signatures at the front of the MAR sheet file. • Photographs of each person should be with their MAR sheet to aid identification. The Retreat DS0000060002.V342548.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 good. This judgement has been made using available evidence including a visit to this service. People are confident in the knowledge that any concerns they may express will be listened to and acted upon. Systems are in place that safeguard people from possible harm or abuse. EVIDENCE: The Commission has received three complaints two which were referred to social services and one which was dealt with by the Manager. The Manager appropriately dealt with the concerns, but complainants dealt with by social services were not fully satisfied with the outcome. People spoken to during the inspection and via comment cards say that if they have any concerns they would speak to the manager, owner or staff. Relatives/advocates/Social workers said they are aware of the complaints procedure and would speak directly to the manager if they have concerns or worries. New booklets have been placed in each room stating how to make a complaint. There are informal and formal meetings at the home that provide another forum for people to express their concerns. 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 kept in the home. The manager encourages the keyworkers to contact the The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 20 relatives/advocates weekly to encourage communication and this contact is documented in the care file. All comment cards returned from staff indicated that they are aware of adult protection procedures. There was evidence that staff attend training in Abuse Awareness and that further training will be arranged when the new safeguarding adults policy and procedure are introduced in Gloucestershire. Staff who have completed their NVQ Awards will also have completed a unit on abuse. A copy of the ‘alerter’s guide’ and the Local Adults at Risk information produced by the local adult protection team should be displayed in the home. The manager is aware of the implications of the Mental Capacity Act and will arrange training for staff in due course. Information about how to access IMCA’S will be made available to people. Recruitment practices within the home are good and comply with Regulation 19. The Retreat DS0000060002.V342548.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, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical environment provides for the individual requirements of people living at the home. The home is appropriate for the lifestyle and needs of individuals and is homely, clean, safe and comfortable and complies with infection control standards. EVIDENCE: The standard of the environment in this home is good with people having a pleasant, clean and well-maintained environment to live in. A walk around the environment was conducted and most bedrooms were seen. Maintenance and redecoration issues are addressed as and when needed. The maintenance book needs re-implementing to evidence when and how things are dealt with and to provide evidence for auditing purposes. The following maintenance issues were raised with the manager and require dealing with: - The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 22 • • • • The radiators in the home should be protected to prevent accidents, as they are not a type that maintain a low surface temperature and hence pose a health and safety risk to people living at the home. Extractor fans (Expelairs) in toilets and bathrooms were dirty and blocked with dust particles, these require cleaning. The Communal bathroom on the first floor the bath has a wooden/board side this needs replacing or covering, as the surface is not a nonpenetrable surface and cannot be washed satisfactorily and thus presents an infection control hazard. In ‘J’s room the Television flex from the TV to the plug presents a health and safety hazard as someone could catch the wire and the television would fall on the person. The home has a ‘lived in’ feel with evidence of personal touches – pictures, photographs, decorations, magazines, books, CD’s and videos in the communal area. There was evidence in rooms seen that individuals had brought their own furniture and possessions with them and had been involved in the decoration etc of their rooms. Some people’s own rooms have sensory equipment for creating a stimulating environment using bright colours, lights and mobiles. People with special needs have all the equipment they need. There was evidence that staff are provided with personal protective equipment that is accessible throughout the home. The laundry is clean and well ordered with washable walls and floor surfaces and hand washing facilities. All staff have a responsibility for overseeing the laundry and cleaning in the home and good practices were observed to be in place. Several of the people living at the home assist with supervision in the laundry and doing the cleaning in the home and thoroughly enjoy doing this. There are records for the cleaning schedules. Hazardous products are locked away and data sheets/risk assessments are kept in a file in the home. There is specific cleaning equipment for each area of the home. The home meets infection control standards and staff seen confirmed they had received infection control training, records confirmed this. The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 23 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 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent staff team deliver a person centred approach to people’s care. They have access to training programmes to ensure they have the knowledge and skills necessary to provide care for the diverse needs of people living at the home. People are protected by the thorough recruitment practice at the home. EVIDENCE: Pre-inspection information demonstrated that during the day from 7am until 10pm there are at least two members of staff on duty. At night 10pm until 730am there is one waking staff on duty and one ‘sleeping in’ member of staff. Rotas demonstrate sufficient staff on duty at all times to meet people’s needs. There are always more hours available as the Proprietor is at the home each day and the Manager is supernumerary, additional hours are rostered when someone is doing something specific. Pre-inspection information indicated that eleven care staff and the Manager work at the home and there is one person employed who does the driving. One new member of care staff has been appointed since the home was last The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 24 inspected. Recruitment and selection processes are on the whole satisfactory with evidence that at least two references are being obtained as well as proof of identity, an occupational health check and a full employment history. The Manager verifies gaps in employment history. Recruitment practice met Regulation 19 with staff starting work following POVA First and CRB checks. The Manager told the inspector that all new staff work with another carer for the period of their induction, although there were no induction records in place to substantiate what is covered during induction or that they work alongside another carer. Supervision is given throughout the induction period and then starts routinely to comply with the regulations, evidence seen during the inspection. The new member of staff was not available to verify the process only records were examined. The staff member seen on duty confirmed that she enjoyed working at the home and that she enjoyed the variety in her working day and enjoyed enabling people to have an enjoyable quality of life. Training records seen confirmed that all staff receive the appropriate mandatory training and that this is ongoing. Training is well supported by regular supervision sessions and yearly appraisals. This is well recorded in the home and demonstrates staff personal development. The Manager supplied the training matrix for the year. There are eleven care staff and six have completed their National Vocational Training (NVQ) Level 2 or 3 and five are undertaking level 2 or 3, at the present time. This exceeds the 50 required under the care standards act and over the next year the home could have 100 who have achieved NVQ level training. The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 25 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, 38, 39, 41 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are safeguarded by the management systems that are in place that promote independence and choice for people. There is leadership, guidance and direction to staff from the manager, ensuring practice that promotes and safeguards the health, safety and welfare of the people living here. EVIDENCE: Staff confirm that they get good support and leadership from the Manager and that the ethos for the home is to promote as independent lifestyles as possible whilst providing a safe environment for the people living here. The staff team is small and staff meetings take place regularly and the Manager sees staff daily. This means that staff are involved in decisions made within the home. Staff comment cards indicate that the manager is accessible The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 26 and supportive working alongside them in the home. Staff comment that they enjoy their work as it is so varied. People were observed having positive interactions with the manager and staff during the inspection. Staff confirmed that they have regular supervision and annual appraisals that complies with the standards, copies of which were seen on personal files. The manager states that she does adhoc observations of staff practice records need to be in place to confirm this. The manager described some of the systems she has in place to assess the standards of care being provided. People take part in an annual quality assurance survey from which changes and developments are made. A range of other audits are completed for health and safety, cleaning, food hygiene, management, personal monies and medication. The home must develop its quality assurance system by reviewing its performance and writing a quality assurance report to demonstrate continual improvement and development in the service. The Manager needs to produce this report in different formats to enable people living in the home, their relatives/social workers/doctors etc to access and read it. There are good systems in place for people’s personal monies. The Manager described the processes that are in place. Records are audited regularly. Health and safety systems are in place that are monitored and reviewed. The environmental checks and the maintenance issues need to be recorded to evidence the ongoing checks that are informally in place. Water is stored at regulated temperatures and regular tests at outlets around the home need to be re-implemented and recorded to demonstrate monitoring systems within the home. Yearly tests for Legionella are undertaken. The windows are all restricted. Radiators in the home are not of the low surface temperature type or covered and hence present a health and safety risk to people living at the home. Whilst risk assessments are put in place where there is an identified risk or furniture is placed to protect people from contact, this is not a satisfactory solution in the long term for the group of people living in the home and therefore this issue must be addressed. The pre-inspection AQAA confirmed that all equipment is regularly serviced and health and safety checks are in place and that all staff undertake mandatory training yearly. The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 27 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 4 2 4 3 X 4 4 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 3 2 X 3 2 X The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 28 No 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 YA20 Regulation 13(2) Requirement The home must ensure that: • A list of staff signatures is available for those who administer medication so that the administrator can be identified. • Photographs of each person must be with the MAR sheet to aid identification. The manager must ensure that the following care plan amendments are made: • Where there are specific measures in place for dealing with specific behaviour these must be on the support/care record. • A recent photo must be available on all care files. • The Manager 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. DS0000060002.V342548.R01.S.doc Timescale for action 03/10/07 2. YA6 15 03/10/07 The Retreat Version 5.2 Page 29 3. YA24 23(d) & 13(3 &4) The following environmental 03/10/07 issues require addressing: • Extractor fans (Expelairs) in toilets and bathrooms require cleaning. • The identified bath requires a bath side that has a non-penetrable surface to prevent an infection control hazard. • The identified room needs the Television flex fixed so it does not present a health and safety hazard to people living at the home. The home must develop its quality assurance system by reviewing its performance and writing a quality assurance report to demonstrate continual improvement and development in the service. The radiators in the home must be protected to prevent accidents. The environmental checks and the maintenance issues need to be recorded to evidence the ongoing checks that are informally in place. Regular tests of water outlets need to be re-implemented and recorded to demonstrate monitoring systems within the home. 31/03/08 4. YA39 24 (1-3) 5. YA42 13(4a) 03/12/07 6. YA42 13(4a) 03/10/07 7. YA42 13(4a) 03/10/07 The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA5 YA35 YA14 YA35 YA35 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. Induction records to be implemented to include record of working alongside a named carer. Activity and social event files to be implemented for all the people living at the home. All staff to receive Mental Capacity Act training. All staff to receive training in the new Gloucestershire safeguarding adult’s policy and procedure. The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 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. Extracts may not be used or reproduced without the express permission of CSCI The Retreat DS0000060002.V342548.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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