Inspection on 09/08/06 for The Retreat, Quedgeley

This inspection was carried out on 9th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 4 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 06/07/07

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 Mr Tim Cotterell Key Unannounced Inspection 9th August 2006 09:30 The Retreat DS0000060002.V303808.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.V303808.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.V303808.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.V303808.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th November 2005 Brief Description of the Service: The Retreat is a large detached property in Quedgeley providing accommodation for up to fourteen adults with learning disabilities. The home is staffed at all times. Service users are accommodated in single rooms, some with ensuite facilities. The home is located close to a supermarket, post office and other facilities and is on a bus route. Gloucester city centre is approximately three miles away. A large lounge and a separate dining room are provided on the ground floor. There is a substantial garden, which includes an outdoor swimming pool. The Retreat DS0000060002.V303808.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 was an unannounced inspection undertaken over two days. During the inspection the provider, registered manager and staff on duty were seen. Ten of the service users were at home and all were spoken to. Those who were able were seen individually. Comments from staff (6) service users (7) and relatives (8) were received through the Commissions questionnaire and the contents fed back to the registered manager. Generally the comments were positive however, a number of relatives felt there were insufficient staff. The accommodation was inspected and a number of records to include medication and care planning were seen. Service users who were able to comment said that they liked living in the home and that staff were caring and pleasant. The registered manager is anxious to ensure that all standards are met and has worked hard on providing a care-planning format that will provide a tool to meet the individual needs of the service users. She is also seen as someone who leads by example and provides a good role model for all staff. What the service does well: There was a good relationship between staff and service users and it was clear that staff were making great efforts to provide a service, which met the needs of the individual. The registered manager is anxious to improve the activities and is keeping a log of all events and also intends to compile a social history in an attempt to learn more about each person. The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Individual needs are assessed thoroughly before any final admission is made. EVIDENCE: At the last inspection (November 2005) the home was required to complete the Statement of Purpose. The registered manager informed the inspector that the updated statement had been completed and a copy sent to the Commission. A completed assessment of need was inspected and it was evident that the home takes care and time over any new admission and that needs are clearly identified. If it is necessary to consider any mental health issues the home consults with the Community Learning Disability Team. One objective of the home is for them to have more detailed social histories and ways of achieving this are being considered. The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The practice of the home ensures that needs are identified and that responsible risk taking enables a degree of independence. EVIDENCE: All service users have an individual plan which is based on “person centred care”. The plans include the specific problem and the action required. Each aspect of the plan is reviewed monthly. It was recommended that the initial assessment of need is also reviewed. Risk assessments are competed and some discussion took place over the risks involved in bathing service users with epilepsy. The risk assessment should form part of the care plan and also be reviewed at regular intervals. It is recommended that each aspect of the care plan is related to a specific activity of daily living. The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 10 The inspector saw staff talking to service users over a proposed trip out. The choice was that they could go on the trip or if they wanted stay at home as staff were available for each option. A number of service users expressed a wish to stay and felt able and comfortable to say this. They were approached in a calm and sensitive manner and it was evident that this enabled them to exercise a choice and convey it to staff. Service users who are able to exercise a degree of responsibility and this was evidence by one lady who was going into the town on her own. The exercise had neen risk assessed and responsible risk taking was seen as part of the practice of the home. The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home has made great efforts to identify individual needs and to ensure the home is a part of the community. Families are encouraged to keep contact where service users request this. The food provided is varied and balanced. EVIDENCE: In the last inspection report it was noted that a number of the service users did not have any formal day activities. The inspector was shown individual programmes and this included a record of the activities undertaken in the home and in the community. It is anticipated that a number of service users will enrol in the local college this autumn. There are also some evening activities in the local community. The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 12 It was clear that a few of the service users were happy not undertaking many activities and this included one older person who clearly expressed his wishes to staff. It is hoped to complete detailed social histories for all service users and this will provide clearer pictures for staff and also identify interests and potential activities. Annual holidays are now organised in a manner, which responds to individual needs and the large group outings are being replaced by breaks that are chosen by and suit the individual. Families and friends are made welcome in the home and staff were aware of the need to ensure the basic rights of the service users are protected. A number of meals were prepared during the inspection. Service users are able to have at least one choice and meals were served in a professional manner. Staff were at hand at the meal table and gave sensitive help and support where this was needed. The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Failure to maintain adequate records of the administration of medicines places service users at risk. The home is aware of the specialist supports available and there is evidence that they are consulted as and when necessary. EVIDENCE: Service users are given the support they require. Health care needs are identified and met through the usual community services. The local surgery is close to the home and there are individual records of all visits and treatments. A number of the service users have specialist care and this is provided through the Community Learning Disability Team. The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 14 The home has recently contacted the Community Learning Disability Team and received advice about the management of certain behaviours. All staff have been trained to administer medication and this competence is reviewed by the home. The home are hoping to change the system of administration to the NOMAD procedure as they feel this would be safer. The local GP practice is agreeing the household remedy list and his authority is awaited. It is recommended that the home has a new “BNF” guide, which identifies individual medicines and gives useful information about them. A number of the administration sheets were inspected and some contained omissions, and it was not clear if the medication had been administered overlooked or refused. The issue of the omissions is being investigated by the registered manager and a review of signatures is essential to ensure a good audit trail is kept. The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users live in an environment where their views are sought and where they are protected from abuse EVIDENCE: The complaints procedure is in the Statement of purpose and a summary in pictorial format will be included in the service users guide when it has been completed. The home has recently incorporated the actions required by staff when a matter was to be referred to the adults at risk team of Gloucestershire County Council. This is included in the complaints and protections section of the Statement of purpose. The registered manger was clear about the need to ensure service users are protected from any form of abuse. All existing staff have received formal training in the identification of abuse and are to be updated. A record of all the monies received on behalf of the service users is held and this is managed by the registered provider. Evidence was seen of the income of allowances (personal and disability living allowances) and of the subsequent expenditures. Each expenditure has a receipt and this is audited by a specific invoice number. Each service user has a bank account where all monies are held and the provider is the corporate appointee. The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 16 Two complaints are being investigated. One the home is dealing with refers to a matter which the home dealt with in 2005. The other was passed by the Commission to the Purchasing section of Gloucestershire County Council. The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home was found to be clean and has been maintained to a good standard. EVIDENCE: With the exception of two bedrooms which were locked as service users were away all of the accommodation was seen. All service users have single bedrooms some of which are en suite. All of the accommodation is accessible and the bathrooms and toilets are situated in various parts of the home and offer the support and specialist equipment which is based on the needs of the service users. The inspector was informed that the lounge area is to be refurbished and the lounge furniture replaced. One bedroom requires a wash basin and this is being done in conjunction with the refurbishment of the room. The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 18 The rear garden is level and well maintained and includes a pool and patio area. Service users are supervised when using the facilities. The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The existing staffing arrangements found at the time of the inspection could place service users at risk and their individual needs will not be met. Staff on duty were seen as caring and sensitive to the needs of the service users. EVIDENCE: On the morning of the first day of the inspection there were two members of staff on duty and they were responsible for, the supervision of the service users, any ancillary duties e.g. cleaning and laundry and the preparation and delivery of the meals. The timetable which had been compiled by the manager indicated that three staff were on duty. It appears staff had changed shifts and failed to cover the original times. The inspector advised the manager that the home must have a system, which ensures the arrangements made by the manager are carried out. The majority of the service users were at home during the inspection as the college and Adult Opportunity Centres were closed for the summer holidays The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 20 and it was evident that the staffing provided was not enough to meet the needs of the individual or indeed the group. During the mid morning of the first day of the inspection with two staff on duty one carer was cleaning a bedroom and the other having to supervise individuals and make some preparations for the lunch. Without having identified the needs of each individual it is not possible to be precise in terms of what hours are required each day however what can be said is that when service users are at home there must be at least three carers who ideally have no other duties. The home must therefore review staffing needs and as well as meeting the minimum numbers on duty, review the arrangement for meeting ancillary needs e.g. cooking and, cleaning and laundry work. A copy of the review and its findings must be sent to the Commission and should be completed by 30 October 2006.A numbers of staff records were seen. Four of the staff were seen individually during the two day visits. It was clear that they were committed to providing a caring and flexible service but the lack of resources often hampered this objective. A number were undertaking NVQ studies however there is an urgent need for training in a number of areas e.g. learning disabilities and managing challenging behaviours. In the circumstances a training programme should be drawn up with clear time scales. The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home operates in an open and inclusive manner where the views of service users and relatives are considered. EVIDENCE: It is essential that the management ensure that minimum staffing requirement are met at all times. The registered manager had a good understanding of the needs of the service users and was seen to take time to sit and talk about some matters which concerned them. The discussions were seen as taking place in a calm and caring manner and one in which the needs of the individual were paramount. The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 22 The manager is on the staff rota and works in the home in a full time capacity; the registered provider calls at the home several times a week and looks after the financial affairs to include the allowances for service users. The registered provider meets the manager formally once a month and this is when the “visits by the registered provider” regulation is met. The home has recently completed a risk assessment in respect of the building and this included the Fire and Rescue aspects of safety. The health and safety of the individual service users is seen as important and the environment provided at The Retreat was seen as domestic but where a risk had been identified steps had been taken to reduce the possibility of an accident/injury. The home has introduced a quality assurance questionnaire and this has been sent to parents and professionals and the home feels the responses were positive and that the exercise was useful. The response from service users to the Commissions inspection questionnaire was good and they were complimentary about the care received from staff. There was a number of issues raised and they were discussed with the registered manager. The response from relatives to this questionnaire was generally positive, however some felt that there was insufficient staff at home and that they were not aware of the homes complaints procedure. The issues were discussed with the registered manager. The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 23 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 4 5 CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 X X X 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 x ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000060002.V303808.R01.S.doc 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Retreat Score 3 3 1 x 3 X 3 X X 3 X Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 12 Requirement Timescale for action 09/08/06 2. 3. 4. YA6 YA6 YA9 18 18 17(2) Schedule 4 The home must ensure that there is a record of all administration of medicines and ensure they are able to identify who undertook the administration. 1) The home must ensure there 09/08/06 are sufficient staff on duty and that they are suitably trained. The home must formally review 15/10/06 the staffing needs of the home to include care and ancillary duties The management of the home 09/08/06 must ensure that any changes in the staff rota are known and agreed by them. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Unit 1210, Lansdowne Court Gloucester Business Park Brockworth Gloucester GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Retreat DS0000060002.V303808.R01.S.doc Version 5.2 Page 26 - 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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