This inspection was carried out on 16th June 2005.
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 made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
CARE HOMES FOR OLDER PEOPLE
Cotswold Spa Retirement Residence Station Road Broadway Worcestershire WR12 7DE Lead Inspector
Yvonne South Unannounced Inspection 16th June 2005 14:00 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 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 Older People. 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. Cotswold Spa Retirement Residence E52 S18644 Cotswold Spa V228707 160605.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Cotswold Spa Retirement Residence Address Station Road Broadway Worcestershire WR12 7DE 01386 853523 01386 852403 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Cotswold Spa Retirement Hotels Ltd (wholly owned subsidiary of Four Seasons Healthcare Ltd) Mr Robert Strzelczyk Care Home 20 Category(ies) of OP Old age (20) registration, with number PD(E) Physical disability over 65 (20) of places Cotswold Spa Retirement Residence E52 S18644 Cotswold Spa V228707 160605.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: At the time of this inspection the home provides 10 places for nursing care and 20 places for personal care. Date of last inspection 22 November 2004 Brief Description of the Service: Cotswold Spa is located in the village of Broadway. The home is in an older building converted for use as a care home. It is on a bus route, and has a garden that can be used by service users although access is not possible for the less mobile. Cotswold Spa provides care services for older people, who are accommodated on three floors of the home. The home provides 18 single and one double occupancy bedrooms. Access to each floor is gained via a central passenger lift or via a staircase. There are two communal lounges and a communal dining room. Initially registered to accommodate service users requiring assistance with personal care, the home has extended its registration to enable accommodation for up to ten people with nursing care needs. An application is currently being considered by the Commission for Social Care Inspection to increase this to twenty peeople with nursing care needs. If approved this will enable the home to provide a service for a maximum of twenty people who need either personal or nursing care. The care service is provided by Cotswold Spa Retirement Hotels Ltd, a member of Four Seasons Health Care, who lease the building from a landlord. The regional manager with responsibility for the home is Ms Jo McPartlane
Cotswold Spa Retirement Residence E52 S18644 Cotswold Spa V228707 160605.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This routine announced inspection was the first inspection to be undertaken in the year 1st April 2005 to 31st March 2006. It took place over three hours during the afternoon. The inspector spoke to four service users and the manager and inspected a sample of two service users records. It was the first inspection undertaken with the newly appointed and registered manager Mr Strzelczyk and focused on the outcomes of requirements made following the previous inspection and standards 3 to 12. (With the exception of 6 and 11.) The registered providers have made an application to vary the conditions of their registration to enable them to offer personal or nursing care to all twenty service users. Consideration was also being given to this application during the inspection. What the service does well: What has improved since the last inspection?
Cotswold Spa Retirement Residence E52 S18644 Cotswold Spa V228707 160605.doc Version 1.30 Page 6 Although the deputy manager and staff team had managed well in the absence of a manager the appointment of someone to the post and his successful application for registration is a positive move forward. The manager has reviewed the care records and plans to support staff to improve these in the future. His standards and expectations are high. Service users have accepted him and appreciate the assistance he has given them. 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. Cotswold Spa Retirement Residence E52 S18644 Cotswold Spa V228707 160605.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Cotswold Spa Retirement Residence E52 S18644 Cotswold Spa V228707 160605.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 4, 5, The home is able to meet the physical and nursing needs of the people who lived there. EVIDENCE: Standard 1 was not inspected on this occasion. However the statement of purpose and service users’ guide had just been updated to reflect the change in management. If the application to vary the conditions of registration is approved by the Commission for Social Care Inspection the document will need amending again to reflect this change and the changes to staffing, experience and training/qualifications. The manager has been asked to provide the Commission for Social Care Inspection with an amended copy when the result of the application is known. The file of a service user receiving personal care and a service user receiving nursing care were inspected. One of these persons had been admitted to the home in 2003 and the other before the National Minimum Standards came into force 2002.
Cotswold Spa Retirement Residence E52 S18644 Cotswold Spa V228707 160605.doc Version 1.30 Page 9 It was clear that a more thorough pre admission assessment had taken place with the person most recently admitted to the home. All topics had been addressed, although the information was somewhat limited at times. The manager said that ideally people visited the home and came for a respite stay to enable them to come to a decision on their future residence. They could then change their minds at any time if they wished. A notice period of four weeks was required. The records indicated that the home was able to meet the needs of the people who lived there. The inspector spoke to four service users and this was endorsed by them. Cotswold Spa Retirement Residence E52 S18644 Cotswold Spa V228707 160605.doc Version 1.30 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 Systems and support were in place that enabled personal and health care needs to be met. Medication storage is not sufficiently strong to be secure. Medication records do not always indicate staff accountability EVIDENCE: Two care plans were inspected. They were clear and easy to follow. All assessments and plans were regularly being reviewed and service users or their representatives had signed to indicate involvement and awareness of the content and their agreement with it. Daily records had been maintained in clear detail. A requirement had been made relating to care plans in the previous inspection report. This had been met. Care plans reflected acute changes in health care needs. Cotswold Spa Retirement Residence E52 S18644 Cotswold Spa V228707 160605.doc Version 1.30 Page 11 Service users confirmed that their health care needs were being met. They were able retain their own GP on admission if the home was in the surgery’s catchment area. They saw their GP when they asked and when the staff considered it advisable. Hospital appointments were kept and the staff gave support. They said that the staff were sensitive and respectful. It was observed that relationships were appropriate. Three requirements had been made in the previous report relating to medication. They were, 1. Service users’ pulse must be taken and recorded prior to the administration of Digoxin. 2. Any manual alterations to MAR charts must be signed by two registered nurses to confirm accuracy and authenticity. 3. MAR charts must be signed each time medication is administered to a service user. During this inspection it was observed that medication records were generally well maintained. The manager said that service users’ pulses were not checked prior to every dose of Digoxin being taken but frequently enough to monitor the person’s condition. If the home’s application to extend the nursing care provision is approved this monitoring will need to be reviewed and carried out for every service user receiving nursing care who is prescribed Digoxin. The author had not signed a handwritten entry to a MAR sheet. This should be done even if the entry is only to state that a drug had been ‘stopped’. One record was seen with two ‘ticks’ instead of signature/initials of the medication administrator. Medication storage was not acceptable. The cupboard for controlled drugs did not comply with the Misuse of Drugs (Safe Custody) Regulations 1973 and other medication was stored in a cupboard made of wood. Although these cupboards were locked inside a walk in cupboard they should still meet the standards set down by the Royal Pharmaceutical Society and Legislation. The manager undertook to check that all service users had access to lockable storage in their rooms. All medication managed by the home was administered by the trained nurses. Service users considered that the staff were ‘kind, helpful, lovely’. One person said that some times she was not happy but she was prone to depression and had never ‘fell out with anyone’. Privacy and dignity was respected. Cotswold Spa Retirement Residence E52 S18644 Cotswold Spa V228707 160605.doc Version 1.30 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 The service users live the style of life they chose. A wider choice and availability of recreational activities and stimulation would benefit mental health and well being. EVIDENCE: Three service users were in a communal lounge ‘watching’ the television. Two spoke to the inspector. One person sat in the reception area and two others were in their rooms. Another person was in his room but did not have the ability to communicate. Those who responded said that they were happy. They received visitors, watched television, read books or ‘did nothing’. There was a notice board in the dining room where information relating to activities and social events could be displayed. Service users were also reminded on the day. The manager said that individual activities were usually more successful than group activities however recently an entertainer had been well received so a return booking had been made. The vicar called regularly and gave Holy Communion to those who wished to receive it. The hairdresser visited regularly and this prompted a lot of conversation and were lively occasions. Outings had been arranged in response to requests but the interested parties had all withdrawn before the event had taken place.
Cotswold Spa Retirement Residence E52 S18644 Cotswold Spa V228707 160605.doc Version 1.30 Page 13 The staff team was being enlarged and the manager intended that this would enable more activities to take place in the future. Cotswold Spa Retirement Residence E52 S18644 Cotswold Spa V228707 160605.doc Version 1.30 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed during this inspection. EVIDENCE: Cotswold Spa Retirement Residence E52 S18644 Cotswold Spa V228707 160605.doc Version 1.30 Page 15 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed during this inspection. EVIDENCE: Cotswold Spa Retirement Residence E52 S18644 Cotswold Spa V228707 160605.doc Version 1.30 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed during this inspection. EVIDENCE: Cotswold Spa Retirement Residence E52 S18644 Cotswold Spa V228707 160605.doc Version 1.30 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed during this inspection. EVIDENCE: Cotswold Spa Retirement Residence E52 S18644 Cotswold Spa V228707 160605.doc Version 1.30 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x
COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x Cotswold Spa Retirement Residence E52 S18644 Cotswold Spa V228707 160605.doc Version 1.30 Page 19 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. 2. 3. Standard 9 9 9 Regulation 13(2) 13(2) 13(2) Requirement Hand written additions to the Medication Administrations records must be signed. Medication records must be signed not ticked. Medication storage must meet the standard required by Legislation and the Royal Pharmaceutical society Timescale for action Immediate & ongoing. Immediate & ongoing. 30th September 2005 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. Refer to Standard Good Practice Recommendations Cotswold Spa Retirement Residence E52 S18644 Cotswold Spa V228707 160605.doc Version 1.30 Page 20 Commission for Social Care Inspection The Coach House John Comyn Drive, Perdiswell Park Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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