Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 23/05/06 for Cotswold Spa Retirement Residence

Also see our care home review for Cotswold Spa Retirement Residence for more information

This inspection was carried out on 23rd May 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service provides a warm welcome to everyone who visits. There is a pleasant atmosphere and frequently the residents and staff can be heard laughing and talking together and singing to themselves. The staff relate well to the residents and respond with kindness and understanding. They have been described by a relative as providing the `best of care` and residents said that they were well cared for and happy.

What has improved since the last inspection?

Since the last inspection a new manager has been appointed and registered by the Commission for Social Care Inspection and a handyman has been appointed. A programme of redecoration and maintenance has been commenced and a staff training programme has been implemented.

What the care home could do better:

The guidance regarding individual care needs available to care staff could be increased to provide them with more detailed information. Residents could also benefit from a wider choice of activities and more interaction with the community. The staff team needs to be increased in number so that staffing levels do not fall due to sickness. A system must be used to monitor the quality of the service provided and continuously work towards further improvement. Health and safety could be improved by ensuring the risks in the home are known and reduced where possible, a qualified first aider is on duty at all times and routine checks of the fire safety systems are regularly undertaken.

CARE HOMES FOR OLDER PEOPLE Cotswold Spa Retirement Residence Station Road Broadway Worcestershire WR12 7DE Lead Inspector Y South Unannounced Inspection 23rd May 2006 09:30 X10015.doc Version 1.40 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 Cotswold Spa Retirement Residence DS0000018644.V294408.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 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 DS0000018644.V294408.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cotswold Spa Retirement Residence Address Station Road Broadway Worcestershire WR12 7DE 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) 01386 853523 01386 852403 Cotswold Spa Retirement Hotels Limited (wholly owned subsidiary of Four Seasons Healthcare Ltd) Mrs Rosemary Ann Harris Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20), Physical disability over 65 years of age of places (20) Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2005 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 full access is not possible for the less mobile. Cotswold Spa provides nursing care services for older people, who are accommodated on three floors of the home. The home provides 18 single bedrooms and one double occupancy bedroom. 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. Information regarding the home can be obtained from the Statement of Purpose and the Service Users’ Guide, which are available in the home, and copies of the Inspection reports are available on request from the manager. Cotswold Spa Retirement Hotels Ltd, a member of Four Seasons Health Care, who leases the building from a landlord, provides the care service. The regional manager with responsibility for the home is Ms Karen Houghton. The manager of the home is Mrs Rosemary Harris. The registered manager said on 17.05.06 that the monthly fees were £2600. Additional charges are made for hairdressing, newspapers and chiropody. Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection incorporates information received by the Commission for Social care Inspection since 06.12.06 and the information obtained during a site visit on 23.05.06. The site visit extended over seven and a half hours during which the inspector spoke to three residents, three staff, the manager and one relative. A partial tour of the premises was undertaken. Questionnaires were sent to the residents, relatives and health care professionals by the Commission for Social care Inspection and to date three responses have been received. The focus of this inspection was on the key care standards and the requirements and recommendations that arose out of the previous inspection. What the service does well: What has improved since the last inspection? Since the last inspection a new manager has been appointed and registered by the Commission for Social Care Inspection and a handyman has been appointed. A programme of redecoration and maintenance has been commenced and a staff training programme has been implemented. Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 Page 6 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 DS0000018644.V294408.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 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 the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are assessed before they are accepted into the home in order to confirm that their care needs can be met. EVIDENCE: The records of three residents indicated that assessments were made of the care they needed before they moved into the home. More detail could have been included. Questionnaire responses indicated that residents and their relatives were provided with all the information they required to enable them to make a decision regarding the home and the staff confirmed that the Statement of Purpose and Service Users’ guide were readily available. Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 Page 9 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 the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual care plans are available to advise staff on the care that must be provided and monitor changes in needs. Medication management ensures residents receive their medication safely as prescribed. EVIDENCE: The records indicated that care plans had been drawn up providing staff with guidance on how to meet the individual needs of each resident. More detail was needed in the description of care plans relating to personal care needs and activities and stimulation. An excellent document had been completed by a relative for one resident providing a detailed social assessment. This would be a useful document for all residents. No information was provided that indicated new residents had been offered the keys to their bedroom door and lockable storage. Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 Page 10 There was no information regarding residents’ wishes relating to their terminal care and death. Risk assessments had been undertaken and health care assessments and care plans were in place. Residents and relatives confirmed that doctors visited when required and health care needs were met. They were very appreciative of the care they received. One relative said that she wished her mother had moved in a lot sooner. The communication between relatives and staff was observed to be very good. Medication management was acceptable. Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 Page 11 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 the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have access to a limited range of activities and stimulation and are able to make choices regarding their care and lives. Visitors are welcomed according to the wishes of the residents and the residents are provided with a menu choice and meals that they enjoy. EVIDENCE: Residents said that they passed their time watching the television, videos and receiving visitors. The documentation described residents as enjoying musical videos and quizzes. The manager explained that a video was usually put on each morning and in the afternoons quizzes and games were organised for those who wished to join in. A programme was displayed. This was used as a suggestion list so that staff could offer a choice and provide the activities that the residents chose. A relative commented that her mother was able to make choices and decisions regarding her care and life and the staff were kind and good. Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 Page 12 The menus indicated that a choice was provide for the main meals and the residents confirmed that they enjoyed their meals. Visitors were always welcome and the new manager had arranged a meeting for the next day when she hoped to meet relatives and talk to them about the development of the care in the home. There was very little community contact. The manager was aware that this needed to be developed. The Vicar came to the home each month and held a Communion Service for those who wished to join in. Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 Page 13 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 the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents, relatives and staff are able to raise any concerns they may have and are confident that they will be listened to. Staff are appropriately recruited and trained to ensure the safety of the residents in the home. EVIDENCE: A complaint procedure was available in the Service Users’ Guide and there was copy for each resident in their bedroom. In addition a copy was displayed in the entrance to the home. Residents confirmed that they had no complaints or anxieties but knew who to speak to should the need arise. The staff also confirmed that they were aware how to raise their concerns. A system was available to record complaints received and responses. Concern had been expressed to the Commission for Social care Inspection and the home regarding staffing levels. On going efforts are being made to address this. Recruitment was in progress. A complaint had been made to the home regarding the invasion of a resident’s privacy by another resident. It was observed, and the manager confirmed that action was being taken to respond appropriately to the needs of both people. Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 Page 14 Another issue raised with the home had concerned the premises and this had been addressed. Appropriate policies and procedures were readily available to guide staff in the protection of vulnerable adults. Training was also being planned and the records confirmed this. Staff had been appropriately recruited. Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 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 the following standard(s): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents are able to live in a clean comfortable environment that suits their needs. Due attention is given to reducing the risks of cross infection. EVIDENCE: The premises had been neglected in the past. However now that a handy man was in post matters were being addressed. Two bedrooms and a lounge had been redecorated and a maintenance programme implemented. The respite room was observed to be spacious, well decorated and furnished and a new carpet had been laid. Unfortunately soon after commencing his duties he was called to do jury service so the momentum had slowed down. This had also had an impact on the garden maintenance where attention was sorely needed. The laundry floor had been repaired and a programme implemented to clean carpets throughout the home and replace them where necessary. Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 Page 16 The heating system had been problematic for a long time. The manager said that a new boiler was to be fitted this summer. A large quantity of old unwanted items had been removed from the building and there were plans to change around the use of the nurses’ room, the hair dressing room and the spa room so that the arrangement was better for the residents and staff. It was observed that the home was clean and there were no offensive smells. Staff had access to gloves and aprons, the home had a contract with a firm to remove clinical waste and communal bathrooms and toilets were provided with liquid soap and disposable towels. Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 Page 17 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient suitable staff are employed to provide the care that is needed but the staffing levels can be adversely affected by sickness as the team is small and there is little flexibility. The provision of staff training ensures that skills and knowledge are kept up to date so that appropriate care can be provided. EVIDENCE: The duty roster indicated that an acceptable level of staffing was provided. However difficulties arose when people fell ill. One person had been off sick for a long time and this had put a strain on the team. Previously some staff had had undertaken both care and domestic duties but this had been addressed and the staff team was now comprised of care staff and ancillary staff. The manager interviewed one person on the day of the inspector’s visit and was recruiting another care assistant. Interviews were to take place during the next week. Consideration was also being given to increasing the number of relief staff. The records indicated that an acceptable recruitment procedure was in use. Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 Page 18 The inspector spoke to two members of staff who confirmed that they were trained to NVQ level two, and to one of the trained nurses. It was observed and confirmed by staff that training was now being provided. A training needs analysis had been undertaken and a programme to meet the identified needs had been drawn up and was being implemented. The manager said that she also proposed having weekly training sessions and was hoping to arrange for monthly talks from specialist speakers. This is a most encouraging improvement in the provision of training. Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 Page 19 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced and competent person who is proactive in developing the service and home to benefit the residents. Health and safety risks need to be assessed so that they can be managed EVIDENCE: A new manager was appointed in March and has been registered by the Commission for Social Care Inspection. She was undertaking the Care Managers’ Award course and hoped to complete it within the next six months Staff and residents confirmed that she was approachable, easy to talk to and was making a lot of changes that were benefiting the residents and the home. Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 Page 20 Although the area manager visited the home nearly every week, and the manager said that she monitored various systems that were in use, there was not a recognised quality assurance system in use. The previous manager had apparently distributed questionnaires in January but the responses and outcomes were not known. Therefore the new manager intended distributing the forms to the people who attended the meeting on the 24.05.06 and would be actively seeking views as to how the care service and home could develop. Policies and procedures had been recently reviewed and were readily available to staff. It was observed that residents’ personal monies were well managed. There was safe storage and good documentation. Staff confirmed that they received supervision and had had appraisals. This had been endorsed by the documentation kept. Health and safety matters were being addressed. However there were no risk assessments for the building, equipment or gardens. This needs to be developed. Only two staff were qualified First Aiders having successfully completed the four day first aid at work course. This needs to be addressed, as there should be a qualified first aider on duty at all times. The fire log was assessed. Documents were contained in two files that held many historical records and rendered the files heavy and difficult to use. The routine checks were not up to date due to the absence of the handy man. It is essential that someone else take over these duties until he returns. A fire risk assessment for the home was not available. The manager has agreed to undertake a range of health and safety training before the end of this year. This includes Health and Safety for Managers, Residential Care Manager’s Fire safety Course and the Four-day First Aid at Work course. In addition the staff will update all health and safety training topics. Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 Page 21 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 X 3 3 3 2 Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP27 Regulation 18 Staffing numbers and skill mix must be appropriate to the assessed needs of the service users, the size, layout and purpose of the home, at all times. A timescale for 31.12.05 had not been met in full. 2 OP33 24 There must be an effective quality assurance and quality monitoring systems in place, based on seeking the views of residents to ensure the aims and objectives of the Statement of Purpose are met and the service develops and improves. 3 OP38 13 Risk assessments must be drawn up for the premises and work routines that effectively reduce the risks of accidents occurring. 01/11/06 01/11/06 Requirement Timescale for action 30/06/06 Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 Page 23 4 OP38 13 A qualified first aider with a current Four Day First Aid at Work qualification must be on duty at all times. Alternatively the home must draw up a risk assessment that identifies that the level of first aid cover is sufficient to meet the needs of the home, and ensure this level of care is in place. A copy of the risk assessment must be sent to the Commission for Social Care Inspection. 01/11/06 5 OP38 23 Fire safety checks must be undertaken in accordance with the advice and recommendations received from the fire authority and a fire risk assessment must be undertaken for the home. 23/05/06 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 OP7 Good Practice Recommendations More detail should be included in care plans relating to personal care, and information should be available regarding the resident’s wishes relating to their keys and their wishes regarding terminal care and death. Endeavours should be made to increase the range of activities and stimulation available to residents in the home and in the community. 2 OP12 OP13 Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Worcester Local Office 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 © 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 Cotswold Spa Retirement Residence DS0000018644.V294408.R01.S.doc Version 5.2 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!