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Please note that the information on this website is now out of date.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 25/05/07 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 25th May 2007.

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.

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 offers a homely atmosphere and a comfortable well maintained environment. Residents say that the staff are kind and caring and a relative said that his wife was well looked after. Health matters are well managed. The doctor and other health professionals are consulted and their instructions and advice is accepted. Medication is well managed and if people wish to manage independently they will receive the support and assistance they need.

What has improved since the last inspection?

Although there are still some weaknesses, the general standard of care recording has improved so the staff have access to better advice and guidance regarding each individual`s needs and care plan. The environment has improved through the rearrangement of facilities, redecoration and furnishings.

What the care home could do better:

The commitment to improving recording should continue as this will ensure up to date information is available enabling the staff to provide the correct care needed. Information should be obtained from each resident or, with their consent, their representative, regarding their care wishes at the end of their life, and their wishes when they die. This will enable staff to provide the correct care in a sensitive manner. The home has a poor record of providing activities and stimulation for residents in the home. No designated staff are employed to take the lead in this. In consequence, unless able to entertain and keep themselves occupied independently, residents can become bored and isolated. The residents can select their meals from a varied menu. One resident states that the choice can be repetitive and the quality of some produce is basic. However local produce and acceptable brands are purchased. Complaints are responded to within the timescale given in the procedure. However when it is identified that action is needed this does not take place in a timely manner. The estates department for the registered providers does not respond and sort out concerns in good time. For example part of the garden could not be used until a retaining wall had been repaired and a resident did not appear to know why there had been a delay. Residents are reluctant to use a small lounge, as the heating is inadequate, a room in the home cannot be put to effective use until unwanted equipment and fittings are removed. The manager has started to implement a training programme to ensure all staff were updated in the essential health and safety subjects. However there needs to be a strong commitment to ensure a well-trained team is achieved and maintained. . Without adequate training staff cannot provide the standard of care residents need and ensure their safety.

CARE HOMES FOR OLDER PEOPLE Cotswold Spa Retirement Residence Station Road Broadway Worcestershire WR12 7DE Lead Inspector Yvonne South Unannounced Key Inspection 25th May 2007 08:45 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.V335633.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.V335633.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 01386 853523 01386 852403 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 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.V335633.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate up to 3 service users with a physical disability between the ages of 60 - 65 years. 23rd May 2006 Date of last inspection Brief Description of the Service: Cotswold Spa is located in the village of Broadway. The home is in an older building (previously used as a hotel) 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 reception area of 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 and the operational director and responsible individual for the registered provider is Pauline Lawrence. The manager of the home is Mrs Rosemary Harris. The regional manager said that the monthly fees were between £2074.06 and £3592.33. Additional charges were made for hairdressing, newspapers and chiropody. Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that incorporated information received by the Commission for Social Care Inspection (CSCI) since the previous unannounced key inspection, which took place on 23.05.06, the information obtained during a unannounced random inspection that took place on 07.02.07 and fieldwork on 25.05.07. The fieldwork took place over eight hours, during which the inspector spoke to three residents and three staff. Documents were assessed and a partial tour of the premises was also undertaken. Assistance was given by the registered manager. The home was asked by the CSCI to complete and return a pre-inspection questionnaire and to distribute questionnaires to the residents and health care professionals seeking their opinions of the service. To date responses have been received from two residents and three relatives. The focus of this inspection was on the key National Minimum Standards. What the service does well: What has improved since the last inspection? Although there are still some weaknesses, the general standard of care recording has improved so the staff have access to better advice and guidance regarding each individual’s needs and care plan. The environment has improved through the rearrangement of facilities, redecoration and furnishings. Cotswold Spa Retirement Residence DS0000018644.V335633.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. The summary of this inspection report can be made available in other formats on request. Cotswold Spa Retirement Residence DS0000018644.V335633.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.V335633.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (An intermediate service is not offered by his home therefore standard 6 was not assessed.) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information and support is available to help people make a decision regarding admission to the home. People are not offered a place in the home unless an assessment has indicated that the service can meet their needs. EVIDENCE: Residents who completed and returned questionnaires to the Commission for Social Care Inspection stated that they had received the information they needed to help them make a decision regarding the home and their future and they had received a contract. Two relatives supported this view. Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 Page 9 The Statement of Purpose and Service Users’ Guide were readily available and the manager confirmed that all new residents received their own copy of the Service Users’ Guide. The care records of three people were assessed. They demonstrated that prior to admission the prospective resident had been visited by the manager and their needs had been assessed. This practice ensured that places were not offered to people who could not be adequately cared for in the home. Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive the personal and social care they need. Staff receive most of the information and guidance from documentation so that care is provided in a consistent individual manner. However the lack of involvement by residents can lead to the wishes of the resident being overlooked. EVIDENCE: Following the random inspection undertaken on 07.02.07 it was recommended that 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. During this key inspection the care records of three people were assessed. It was observed that the care plans covered a range of care needs and were generally acceptable although a bit sterile. It was considered that more individuality would be useful for staff and residents. Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 Page 11 Some weaknesses included a continued lack of information regarding ‘end of life care’, some forms had not been fully completed, and some forms had not been dated and signed. The identity of all prescribed creams that had been applied by staff had not always been recorded and an identified risk of pressure damage had not been addressed with a care plan. The records indicated that other health professionals were contacted and attended as necessary and their instruction were carried out. Generally the standard of care planning had improved. The manager intended developing the record system further by maintaining a ‘core’ file in the office, and the residents’ care (working file) which if acceptable, would be kept in the resident’s bedroom. This latter file would contain documents needed by staff to provide the individual care. The current records showed very little evidence that the resident or, with their consent, their representative had had involvement in the planning of their care. It was hoped that the changes in the access and maintenance of records would also address this. Questionnaires from residents that were returned to the CSCI stated they usually received the care and support that they needed however language and different cultures could cause problems. Some relatives considered that needs were usually met and communication was good. While another stated in the questionnaire response that he received no information regarding his mother’s well being. Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents do not have regular access to a choice of activities or interests in the home or community to enhance the quality of their lives. A varied menu is provided so that residents can select the meal they prefer. However some residents do not like the quality of produce used. EVIDENCE: There continued to be no development in this area of care provision. The questionnaires undertaken by the home and the CSCI supported this view. A resident said that there were very rarely activities arranged that she could take part in and there were some very sick patients in the home who were not really capable of taking part in activities. A relative suggested there was a need for ‘More social entertainment for residents’. An activities organiser was not employed and therefore care staff were responsible to providing social activities and stimulation according to Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 Page 13 preferences and needs, in addition to attending to the residents’ personal care needs. However their time was short and no programme had been set up. The residents ‘abilities and needs were extremely varied. The inspector met three residents. One person was sat in the courtyard enjoying a cigarette and reading her book. She was very content with a warm drink, blanket and call bell available if needed. Another resident was in her room watching her television. The third resident suffered from dementia and was very frail. She was alone in her room in her chair and had very little ability to communicate. The manager said that she was aware that the home did not give a good service in this area and she was trying to address this. A carer was to go on a course for activities and stimulation, a masseur came and carried out some hand massages, one of the agency staff undertook some reminiscence session and a strawberry cream tea was planned. There were residents in the home who belonged to three different Christian faiths. The manager said that contact numbers were available for all religious leaders and the local vicar came to the home to hold a Service each month. Visitors were welcome at all times and the visitors’ book demonstrated that there was a steady stream throughout the day. The sample menus that were seen show a varied choice of diet with some repetitions. A resident commented in the questionnaire; ‘There could be more variety. Also better quality. Tinned fruit etc. is of the cheapest grade. Why not top quality? One gets the impression that anything is good enough for us old folk!! A tight budget for the chef I suspect. The owners of the home are pretty tight-fisted. Only interested in profits.’ Another resident said that she enjoyed her meals. Observation in a store cupboard revealed a small stock of Brakes Brothers own brand tinned goods. The manager said that they received a weekly delivery. Two large freezers held the stock of meat that was delivered each month and fruit and vegetables were obtained locally. The regional manager said that the food was not of a low quality. The tinned fruit was Del Monte. However fresh fruit salad was also offered. The chef was not on a tight budget; indeed the food budget for the home was higher than that in some of the provider’s other homes. Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 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. 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. People have the information and support that they need to help them raise their concerns. However the response by the registered providers can be slow. This could result in people being reluctant to raise issues as they lack confidence in a timely response, even when the issue is warranted. Language differences can make it difficult for some staff and residents to understand each other. EVIDENCE: A copy of the complaints procedure was displayed in the entrance of the home and copies were available in the Statement of Purpose and the Service Users’ Guide. The pre-inspection questionnaire stated that the home had received two complaints and both had been warranted. The records indicated that the complaints had concerned the failure of the registered provider to provide a special bed, a special wheel chair and a new bedroom carpet within a reasonable time, even though the need for such items had been agreed. Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 Page 15 Questionnaire responses received by the CSCI also identified several issues regarding the slow response of the registered providers of the home. These had concerned the maintenance of the grounds, the heating in part of the home, and the provision of a suitable safety chair. Questionnaire responses from residents and relatives stated that they knew how to make a complaint. However one person said; ‘Complaints are not received very well. One is accused of being stressed. Language and different cultures can cause problems.’ One complaint received by the CSCI in May 2006 was investigated, well managed and responded to by the registered manager. The manager received support from the Adult Protection Service as there were concerns regarding family pressure exerted over a resident. The records of two staff were assessed. These demonstrated that they had followed an acceptable recruitment procedure and interviews, references and checks had bee appropriately undertaken. The staff were interviewed and confirmed this. Both people were aware how to respond to complaints and concerns regarding the suspicion or observation of abuse of a resident. The pre-inspection questionnaire indicated that training regarding the protection of vulnerable people had been undertaken. Communication with one member of staff was very difficult due to languages differences. Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are able to live in a pleasant home that suits their wishes and needs. However the estates department does not respond readily to needs that arise so residents are disadvantaged in the use of some areas. Care is taken to protect residents from the risks of cross infection. EVIDENCE: A partial tour of the home was undertaken. There had been great improvement to the premises. The administrator’s office and reception area had been redesigned, decorated, carpeted and furnished. Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 Page 17 The ‘nurses station’ had been moved to a more spacious room and the newly appointed handyman had made great improvements in the home and in the garden. A resident described the handyman as ‘a gem.’ Redecoration of corridors and bedrooms continued. New carpets and blinds had been provided for the lounge and dining room. The hairdresser’s room was used for storage when not needed by the hairdresser, due to a lack of this facility. Residents’ questionnaire responses raised several issues; ‘We have one maintenance man who does his best. But the approaches to the home and near the patio area are a disgrace. I hope to be able to sit out on the patio later on but it is a shambles, (used to be so attractive) also there is a wall, which is liable to fall down. Was going to be repaired months ago but nothing done. Our fees were increased by £100 per week in February, but not much to show for the extra charge. Why not use contract gardeners who can keep the outside up to scratch on a regular basis.’ It was observed that since the questionnaire was completed the entrance to the home and the patio had been attended to and were now pleasant to use. However a retaining wall that held back a raised garden area was badly cracked and appeared in danger of collapse. A resident said that in the past she had been able to walk in the area and the orchard above the retaining wall but it was now overgrown, and inaccessible because of the condition of the wall. The manager confirmed that the area had been cordoned of as the wall appeared unsafe and they were waiting for the estates department to arrange its repair. The regional manager stated that the retaining wall could not be repaired as quickly as they would have liked; firstly as they had to obtain Cotswold Stone in order to ensure that the wall was in keeping with the rest of the building and secondly because of the bad weather. Private fee rates were increased in February by between £25.00 and £35.00 per month. A questionnaire stated that; ‘There is a nice quiet lounge. The radiators have not worked properly in there all winter. It’s a very cold room. A small heater is there for use. One can put it on if anyone arrives unexpectedly. Surely we deserve permanent heat in there. Does anyone care?’ The manager said that the heating in the lounge was caused by thermostats in the radiators sticking. The estates department had agreed to replace all radiators in an effort to resolve the problem. Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 Page 18 A large room still held the remnants of a spa bath that had been installed many years ago when the premises was a hotel. The manager said that the bath was too large to be removed without cutting it up. This would be a specialist job and a contractor was being sought. In the mean time the room could only be used for storage. Everywhere in the home was clean and free of offensive smells. However a questionnaire response, confirmed by a resident stated that; ‘When the housekeeper is on days off or sick, no cleaning is done. What about hygiene and infections? Why can’t they have a contract-cleaning firm to take over at these times? The management say that they can’t get any more staff money once again.’ The manager said that they were recruiting for another member of the housekeeping team, which would resolve this difficulty? The laundry was clean and tidy. The manager said that there had recently been great difficulty as the machines had broken down due to incorrect installation some time ago. The laundry had been out of action for some time. They had managed by using local facilities and when necessary destroying and replacing items. One machine had been replaced and the other had been repaired. Both machines had been re installed and were working when inspected. It was observed that relevant areas in the home were supplied with liquid soap and disposable towels. Staff had ready access to personal protective equipment and the home had a contract for the removal of clinical waste. Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does not have a sufficiently large staff team to enable residents to receive full care from familiar people. The lack of stability and resulting pressure on the staff team impacts in the pursuit of training and their ability to undertake all tasks including the provision of activities and stimulation. Therefore the overall quality of care is compromised. However this has been acknowledged and adjustments have been made to the duty rota to address this. EVIDENCE: Following the key inspection undertaken in 2006 a requirement was made that 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 concerned relative contacted the CSCI in November 2006 regarding staffing levels. A phone call to the home revealed that occupancy was low. However the manager believed that the staffing levels were able to meet the residents’ current needs at that time. Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 Page 20 This was reiterated during the random inspection when occupancy and staffing levels had both increased. The manager said that she had met the relative concerned and was trying to resolve his concerns. The pre-inspection questionnaire received prior to this key inspection indicated that the current staff team comprised three trained nurses, ten care staff and four ancillary staff. Two of the staff came from the Philippines and one person came from India. There were some communication difficulties with one person and the manager said that this was being addressed. The pre-inspection questionnaire and the manager stated that since the last inspection five staff had left the employment of the home and one person was on long term sick. Recruitment was in progress for another trained nurse and a domestic but in the interim it had been necessary to employ staff from an agency for a large number of shifts to maintain staffing levels. Two staff were interviewed by the inspector. They both stated that the staffing levels were good and there were no problems in meeting residents’ needs. They could cope well. However a relative stated in a questionnaire response that the consequences of poor staffing levels were seen in the poor standards of care and training The regional manager has said that the duty rotas had now been adjusted to increase the number of staff on duty between 7am and 8am and some staffing issues had been addressed. The pre-inspection questionnaire indicated that four care staff held National Vocational Qualifications (NVQ) and this equated to only 40 of the care staff team. The National Minimum standards require that 50 of care staff have such qualifications. The manager said that there were no staff on courses but two people were interested and she was trying to obtain sponsoring for them. The pre-inspection questionnaire indicated that since the previous key inspection training had taken place with staff in moving and handling, palliative care, fire safety, COSHH, care planning, record keeping, and the protection of vulnerable adults. None the less the training analyses demonstrated that staff still needed training in many mandatory subjects. The manager demonstrated that a training programme had been drawn up and courses had been booked. Questionnaire responses from residents and relatives stated that staff were usually available and they had the right skills and knowledge to look after people properly. Comments made were; ‘As far as my wife is concerned they look after my wife very well.’ ‘Most needs are met.’ Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 Page 21 ‘Carers are very kind and caring, but nursing staff on the whole are not so caring.’ Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The stable management ensures that procedures and systems are in place to provide the residents’ care. However this is compromised by the size of the staff team and the lack of training in some areas. A quality assurance system identifies areas that need attention and development but the resulting action is slow. Training in health and safety matters is not continuously maintained and therefore people in the home are at risk. Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager had been in post for some time. She was appropriately experienced and trained. Staff say that she was approachable and supportive. There was no deputy at the time of the fieldwork. Policies and procedures were in place and had been appropriately reviewed. The registered providers had a quality assurance system that included an annual survey regarding the quality of the service delivered. It was observed that an analysis of the survey results had been placed with the Statement of Purpose. The system was also composed of regular audits of equipment, care, health and safety and training achievements. Two residents held personal money in safekeeping. There was secure storage and records were maintained on computer. The manager confirmed that receipts were given and received for all income and expenditure. The manager demonstrated that a supervision programme was being undertaken with all care staff and records were being maintained. The pre-inspection questionnaire indicated that services and equipment were being appropriately checked. However it was stated that the most recent fire safety drill and training had been carried out on October 2006. A requirement was made following the random inspection that; ‘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.’ During this fieldwork a fire risk assessment was seen that had been carried out by the estates manager on 19.10.06. The inspector advised that the risk assessment should included training. Training records demonstrated that insufficient fire safety training and drills had been carried out with staff. However the manager stated that she and one other had undertaken the fire warden training and full training with all staff was arranged to take place on 30.05.07. An immediate requirement was made that all staff should receive the relevant training on the date arranged and in the interim the person in charge of the home each evening should before going home, ensure that the night staff were aware of the emergency procedures. Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 Page 24 On 30.05.07 the CSCI received a fax from the manager stating that with the exception of three staff (two on leave and one attending other training) fire safety training had been undertaken with all staff. The manager confirmed that the three people who had missed the training would receive it during their first shift in the home. A requirement was also made after the random inspection that; ‘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.’ A copy of the risk assessment was received. However at the time of this field work the number of trained first aiders had further decreased to three. The manager said that she was aware of this and was endeavouring to find places on courses as soon as possible. Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 Page 25 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 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 1 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 Page 26 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 OP38 Regulation 23 Requirement Fire safety training and participation in fire drills must be conducted with all staff according to the fire risk assessment for the home. Guidance from the fire authority should be considered when undertaking the risk assessment. The premises must be kept in a good state of repair externally and internally. Furniture and equipment, identified as necessary to meet a person’s needs, should be provided as soon as possible if that person is to remain in the home. Timescale for action 30/05/07 2 OP19 23 01/11/07 3 OP22 16 01/09/07 Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 Page 27 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 Residents, or with their consent their representative, should be involved in the planning of their care, so their wishes and preferences are known and respected Information should be available regarding the resident’s wishes relating to terminal care and death so these can be carried out appropriately and sensitively. Consideration should be given as to how the service can support staff that are not fluent in the English language so that residents are safeguarded. Sufficient staff should be employed to enable a daily programme of group and individual activities and stimulation to be offered to residents, thereby enhancing their quality of life. Following the investigation of a complaint, identified action and explanation should be taken within a reasonable time scale. All staff should receive mandatory training in care and health and safety matters. This must then be regularly updated to ensure residents receive appropriate care safely at all times. 2 OP7 3 OP29 4 OP12 5 OP22 6 OP30 Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 Page 28 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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cotswold Spa Retirement Residence DS0000018644.V335633.R01.S.doc Version 5.2 Page 29 - 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!