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Inspection carried out on 26 September 2019

During a routine inspection

About the service

Retreat Lodge is a residential care home providing accommodation and personal care. The home accommodates up to seven people in one house. At the time of our inspection seven people with learning disabilities were living at the home.

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

As part of thematic review, we carried out a survey with the manager at this inspection. This considered whether the service used any restrictive intervention practices (restraint, seclusion and segregation) when supporting people. The service used some restrictive intervention practices as a last resort, in a person-centred way, in line with positive behaviour support principles.

People’s experience of using this service and what we found

Staff managed people’s medicines safely and our checks showed people received their medicines as prescribed. Staff understood the risks in people’s care and how to support them safely and the provider had checks in place to manage the premises and equipment safely. The service was clean and staff followed suitable infection control practices. There were enough staff to support people safely and staff were recruited following robust processes.

The provider supported staff with a range of training relating to people’s needs, as well as one to one supervision. People received the support they needed to maintain their day to day health and in relation to eating and drinking. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People were cared for by staff who were kind and understood them well. Staff supported people to be involved in decisions in their care and care was personalised to meet people’s needs and preferences. Staff supported people to access a wide range of activities they were interested in, and supported people on annual holidays. Staff understood people’s communication needs well. The provider had a suitable process in place to respond to any concerns or complaints.

An experienced manager was in post who was in the process of registering with us. The manager was well regarded by staff and relatives. The manager had sufficient oversight of the service, working alongside staff regularly to check high standards were maintained. The provider had a range of audits in place to check standards were maintained at all times.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was requires improvement (report published September 2018).

Why we inspected

This was a planned inspection based on the rating at the last inspection.

Follow up

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

Inspection carried out on 11 September 2018

During a routine inspection

Retreat Lodge is a ‘care home’. People in care homes receive accommodation and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Retreat Lodge accommodates up to seven people with a learning disability and/or autism in one adapted building. The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. At the time of this inspection there were seven people using the service.

We undertook an unannounced inspection on 11 September 2018. At our last inspection in February 2016 we rated the service ‘good’ overall and for each key question. At this inspection we found the quality of service provision had deteriorated and the service was rated ‘requires improvement’. We also identified breaches of two legal requirements relating to safe care and treatment and good governance. You can see what action we have asked the provider to take at the back of this report.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There were not sufficiently robust procedures in place to review, monitor and improve the quality of service delivery. The provider had a system of monthly audits but these did not address all areas of service delivery and we found some key areas of service delivery were not appropriately checked, including medicines management, infection control and the quality of care records. We found the provider had systems in place to obtain feedback from people, relatives and staff, but there was not always sufficient action planning following this feedback to address any concerns raised.

Safe medicines management processes were not consistently adhered to, meaning we could not be assured that people always received their medicines as prescribed and accurate records were not always maintained about medicines administration.

The numbers of staff on duty per shift had recently been reduced. Staff felt the reduction in staff was not yet impacting on the quality of service people received but had increased the chance of people’s routines not being adhered to and the possibility of incidents occurring. The reduction in staff per shift had impacted on staff’s well-being, morale and stress levels. We recommend the provider uses staffing dependency tools to ensure the staffing levels are appropriate to meet people’s needs.

The provider was aware of safe recruitment practices including obtaining references from previous employers, checking employment history, criminal record checks, checking people’s identity and eligibility to work in the UK. However, we found these were not consistently adhered to and therefore we recommend the provider consistently adheres to safe recruitment practices to ensure all staff employed are suitable to support people.

Staff had received regular training and completed the provider’s mandatory training. Staff also received regular supervision and appraisals to ensure they had the knowledge and skills to support people. Staff were knowledgeable and adhered to key legislation including safeguarding adults’, the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards, and infection control procedures.

Staff knew the people they were supporting. This included their individual preferences, as well as their routines, care, health and support needs. On the whole care records were in place that detailed people’s support needs and what was important to them. Care records also included a review of the risks to peop

Inspection carried out on 17 February 2016

During a routine inspection

The inspection took place on 17 and 18 February 2016, and was unannounced.

At our previous inspection of the service on 5 February 2014 the service was meeting the regulations inspected.

Retreat Lodge provides accommodation and personal care for up to seven people who have learning disabilities. There were seven people living in the home when we visited.

The service had a long serving registered manager in post. ‘A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’

People felt safe using the service; they had sufficient numbers of trained staff present to support them. Recruitment procedures were safe and only thoroughly vetted staff were employed. The service had a staff training and development programme. Staff received appropriate training and support to enable them to meet people’s needs.

Staff worked with a range of healthcare professionals to obtain advice about how to support people with their healthcare needs. Staff were implementing care practices that reflected the advice received.

Staff were trained in safeguarding adults. Staff at the service identified risks associated with people’s care and were aware of how to manage these safely. The service ensured that people’s human rights were respected and took appropriate action to assess and minimise risks to people.

Staff demonstrated a good understanding of people’s needs. Staff treated people in a warm and caring manner showing regard for their dignity and individuality. Staff were attentive and responsive to people’s verbal and non-verbal communication; they provided care that took account of their individual needs and capacities.

Staff supported people with identifying goals they wished to achieve whilst using the service and supported them to progress towards them. Staff were aware of the importance of people engaging in suitable and enjoyable activities and leading fulfilling lifestyles. People were offered structure in their lives, opportunities and facilities at the home were good. People were encouraged and supported to participate in a variety of activities in the home and build links in the community.

People were cared for in line with the legal requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). ‘Best interest meetings’ were held as required by the MCA in situations when people could not give consent, for example, for a medical procedure.

The service had systems to ensure the quality of the service was checked regularly and action was taken as necessary to ensure the standards of care were of a high quality. Appropriate action was taken in response to incidents with a view to preventing recurrence. Staff provided people with support, the opportunity and time to discuss any concerns or complaints they had.

Inspection carried out on 5 February 2014

During a routine inspection

We saw that staff took time to explain activities and the support they wished to provide before seeking peoples permission to provide care. Although people had limited verbal communication skills we observed they were able to indicate they understood the support choices available to them. One person we spoke with said, they (the staff) knock on my door, they always do. They ask me what meal I want, I choose.''

We observed that people received safe, appropriate care and support that met their needs and preferences. One relative we spoke with said, ''I don�t have to worry, the staff call me if there is a problem or want to know something but it�s not very often as they know him well by now.''

Prescribed medicines were stored securely and appropriately. We saw that staff had received training to administer medicines safely to people using the service.

We saw that there were effective recruitment and pre-employment checks undertaken to ensure people received care from staff that were fit and appropriately trained to do their job.

The provider had systems in place to ensure people experienced safe quality care and respond to any concerns they might have.

Inspection carried out on 19 January 2013

During a routine inspection

At the time of our visit there were two people using the service. One person was away for the weekend with their family. We spoke with the person who was using the service prior to their going out and being supported by staff in the community. People who use the service said they liked living at the home and being involved in different activities.

Staff were appropriately supported in their work and received regular training.

The environment of the home was maintained, with routine maintenance ongoing to ensure the home was safe for the people who use the service.

Inspection carried out on 21 February 2012

During a routine inspection

At the time of the site visit to Retreat Lodge there were no service users living at the home. However, the service is being maintained and is able to admit people at any time. Therefore the site visit focussed on the home's suitability to admit service users.