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Inspection on 05/10/05 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 5th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

There is a comfortable homely atmosphere in the home and residents and the visitor commented favourably this on. Everywhere is clean, well maintained and attractively furnished. The bedrooms are arranged according to the wishes of the occupant and their own personal possessions are arranged to their liking. One resident commented on her delight in having an attractive room with a view. The residents and visitor expressed their appreciation of the high quality of the care and the kindness of the staff. The maintenance of good relationships with relatives is valued and every opportunity is taken to keep them informed and involve them in the care of their relative according to individual wishes.

What has improved since the last inspection?

Since the last inspection a new medicine cupboard has been purchased and fitted and a special bed has been obtained to meet the needs of one resident.

What the care home could do better:

Although the storage facilities for medication have been improved there is a concern that the room is too warm to keep the medicines in good condition. It has been suggested that this is discussed among the staff as they may have ideas on how the situation can be resolved. The policy and procedure relating to medication records needs a minor adjustment so that it is clear who is responsible when medicines such as creams are applied. Good guidance is available for staff to protect the vulnerable people who live in the home. However the staff need information to reassure them that they will not suffer if they raise concerns themselves. There have been concerns regarding the number of staff on duty at times. Although this was not an issue at the time of the inspection it is important that there are always sufficient staff on duty to help the residents in the home and address health and safety needs. The deputy does not have access to all necessary records or information. This needs to be addressed so that she is able to manage the home effectively in the absence of the registered manager. The fire safety and training records need to be clearly kept so that it is clear what checks have been carried out and who has received training. Also a full assessment of the fire risks in the home needs to be done and appropriate action taken where necessary to reduce risks and ensure safety.

CARE HOMES FOR OLDER PEOPLE Cotswold Spa Retirement Residence Station Road Broadway Worcestershire WR12 7DE Lead Inspector Y South Unannounced Inspection 05/10/05 15:30 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.V251147.R01.S.doc Version 5.0 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.V251147.R01.S.doc Version 5.0 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) Robert Pawel Strzelczyk 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.V251147.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th June 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 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 people with nursing care needs or personal care needs to be accomodated. 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. The manager of the home is Mr Robert Strzelczyk and the responsible individual for the company is Pauline Laurence. Cotswold Spa Retirement Residence DS0000018644.V251147.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection was brought forward as the Commission for Social Care Inspection had been informed of concerns regarding staffing levels. The inspection took place between 3.30pm and 6.30pm. Alice Antonio, the deputy who was in charge of the home at the time, and the other staff on duty, assisted the inspector. The focus was on core standards not assessed during the previous inspection, these related to residents’ rights and protection, staffing and management. Documents were inspected and in addition to the staff on duty the inspector met six residents and one visitor. Not all residents were able to contribute fully. There were thirteen residents accommodated on the day. Some standards could not be fully assessed, as the deputy did not have access to relevant documents or information. In these areas the assessments have not been scored but will be addressed again during a future inspection. What the service does well: What has improved since the last inspection? Cotswold Spa Retirement Residence DS0000018644.V251147.R01.S.doc Version 5.0 Page 6 Since the last inspection a new medicine cupboard has been purchased and fitted and a special bed has been obtained to meet the needs of one resident. 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.V251147.R01.S.doc Version 5.0 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.V251147.R01.S.doc Version 5.0 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): These standards were not assessed during this inspection. EVIDENCE: Cotswold Spa Retirement Residence DS0000018644.V251147.R01.S.doc Version 5.0 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): These standards were not assessed in full during this inspection. EVIDENCE: Three requirements were made relating to standard 9 following the last inspection; 1. Hand written additions to the Medication Administration Records must be signed. 2. Medication records must be signed not ‘ticked’. 3. Medication storage must meet the standard required by legislation and the Royal Pharmaceutical Society. During this inspection the records were seen. There were no hand written additions observed. However some administrations were still identified by ticks. The deputy explained that the nurses made these when they were told that prescribed creams had been applied by care assistants. Ideally the care assistants should initial the MAR sheets themselves. Cotswold Spa Retirement Residence DS0000018644.V251147.R01.S.doc Version 5.0 Page 10 Alternatively a signed hand written addition needs to be made to every such sheet each month referring the reader to the contact records where the care assistant has made a record of the care carried out. It was observed that correct storage had been obtained for medication. However the room in which the cupboard was hung was very warm. The temperature should be maintained between 23c and 25c maximum. It was observed that the room was fitted with an extractor fan, as there were no windows or natural ventilation. If the room cannot be cooled to an acceptable level then the medication cupboard will need to be placed elsewhere. It is recommended that a staff discussion take place to identify a solution. Perhaps the use of rooms can be rearranged so that heat is not an issue. Cotswold Spa Retirement Residence DS0000018644.V251147.R01.S.doc Version 5.0 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): 14, 15 Residents are able to make choice relating to their routines, food and activities. Varied, nutritional and good quality meals are provided from which residents can make their selection. Assistance is available for those who need it. EVIDENCE: The deputy had no involvement in the management of residents’ finances and was therefore unable to provide information on this matter. She was unaware of any advocacy services in use. Therefore standard 14 has not been scored. Discussion took place regarding advocacy and the deputy expressed the intention of trying to obtain a speaker on this subject for the staff. During the tour of the building it was observed that residents had their personal possessions arranged in their rooms and it was confirmed that they could have as little or as much as they wished within the boundaries of safety. A resident confirmed that she was able to make decisions regarding the pattern of her life and she ‘loved her room’. Cotswold Spa Retirement Residence DS0000018644.V251147.R01.S.doc Version 5.0 Page 12 The chef visited every resident each day and obtained their choice of the meals on the menu. Special likes and needs were catered for. The chef said that currently no special diets were needed. The dietician had been consulted when necessary and it was seen that the ‘choice list’ provided a record of food provided. Care records were maintained in the bedrooms of nursing care residents and these contained details of fluids and food consumed. Comments on the standard of the food provided were very complimentary. It was pleasing to observe that the chef was closely involved and spent time with the residents in the home. The deputy said that some residents dined in their rooms and the ability of some people fluctuated. Assistance was given by the staff when needed. Cotswold Spa Retirement Residence DS0000018644.V251147.R01.S.doc Version 5.0 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): 16,18,19 People have access to the information they need to enable them to raise any concerns that they might have. The staff are approachable and supportive which encourages problems to be discussed. The complaint record is not readily available for inspection. Staff have information and guidance to help them recognise and act appropriately to protect vulnerable people but they do not have ready access to a whistle blowing procedure which would inform them of their own legal position and protection if they raised concerns. Without this knowledge there is a risk that they may take no action for fear of victimisation. EVIDENCE: A complaints procedure was available but the deputy had no access to the record of complaints. It is required that these are available for inspection. The deputy said that as far as she was aware no complaints had been received. She was confident that visitors and residents would feel able to bring their concerns to either the manager or herself. As the deputy had no knowledge of advocacy service in use or if the residents were on the electoral roll and enabled to vote if they wished, standard 17 has not been scored. Cotswold Spa Retirement Residence DS0000018644.V251147.R01.S.doc Version 5.0 Page 14 It was observed that a manual of policies and procedures was readily available to all staff and it contained a detailed document concerning the protection of vulnerable adults. However a policy and procedure on whistle blowing could not be found. The deputy said that there had been no related concerns to her knowledge and she was able to give an accurate account of the action to be taken should any be brought to her notice. Cotswold Spa Retirement Residence DS0000018644.V251147.R01.S.doc Version 5.0 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 Residents live in a safe comfortable house that is furnished and equipped to meet their needs. EVIDENCE: A tour of the building was made. No health of safety hazards were observed. The building was well maintained, clean and well decorated and furnished. Bedrooms were comfortable and a resident expressed her appreciation of the home and her bedroom. The deputy said that there were no concerns regarding maintenance and the home had suitable equipment to meet the current needs of the residents. Cotswold Spa Retirement Residence DS0000018644.V251147.R01.S.doc Version 5.0 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 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): 27,29,30 Although there have be problems in the recent past, residents’ current needs are met by the numbers and skill mix of staff. Vulnerable adults are protected by the recruitment procedure used. Training is made available to all staff to enable them to undertake their duties appropriately. Staff are competent to do their jobs. EVIDENCE: The Commission for Social Care Inspection had been made aware of concerns that on occasions in September staffing levels had fallen very low. This had been discussed with the registered manager prior to the inspection and copies of duty rosters provided to the Commission for Social Care Inspection. The concerns had been found valid. The duty rosters that were submitted to the Commission for Social Care Inspection prior to this inspection indicated that the home employed four trained nurses, (these comprised the manager, the deputy and two night staff), five day care staff and three night care staff. Some of the staff covered extra shifts when needed and there were two bank staff that were trained nurses and mostly worked nights. Cotswold Spa Retirement Residence DS0000018644.V251147.R01.S.doc Version 5.0 Page 17 There were two catering staff, a kitchen assistant who also did housekeeping, and an administrator. The deputy said that only the maintenance post was vacant. This is not a large work force to maintain the minimum staffing levels necessary (i.e. one qualified nurse and two care assistants at all times during the waking day and one qualified nurse and a care assistant awake at work at night). The deputy said that the staff were very good and willing to cover extra hours and roles when necessary. However the duty roster demonstrated that most staff were contracted to work in excess of thirty hours. This reduced their availability to work many extra shifts. Therefore, there had been occasions in September when staffing levels had fallen to one qualified nurse and one care assistant. The deputy confirmed that at the time of the inspection, there were no difficulties in maintaining acceptable staffing levels. However, the staffing establishment needs to be reviewed to ensure that it is sufficient to maintain the minimum number of staff on duty and be responsive to increased needs. If these levels cannot be maintained by the provider and their employees, for whatever reasons, then agency staff must be employed or the resident moved to a home where their needs can be fully met. The deputy had no access to any staff files and was not involved in recruitment. Therefore standard 29 has not been scored. The deputy said that the manager was meticulous and always obtained two satisfactory references, POVA and CRB checks, before anyone was appointed. All staff had received a copy of the GSCC code of conduct and a contract. The deputy had no access to training records therefore standard 30 has not been scored. The deputy said that she was a trained nurse who had successfully undertaken the adaptation course. Since coming to Cotswold Spa more than a year earlier she had undertaken further training in a range of subjects. Training courses were available to all trained nurses and in house training was provided for other staff. One of the care assistants had recently undertaken the Fire Warden’s course and would now be taking responsibility for this area of safety in the home. Residents confirmed that they were looked after ’wonderfully’ and the visitor who spoke to the inspector of her mother’s care endorsed this. Cotswold Spa Retirement Residence DS0000018644.V251147.R01.S.doc Version 5.0 Page 18 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): There was insufficient evidence to the judge the outcomes of standards 31, 32, 33 & 35 EVIDENCE: Standard 31 could not be assessed in full due to the absence of the manager. However he had met the requirements and been registered by the Commission for Social Care Inspection. The deputy did not know his recent training achievements. The deputy had no knowledge of any quality assurance system in use but was aware that Jo McPartlane visited the home regularly and checked everything. However the Commission for Social Care Inspection, has not received copies of reports relating to regulation 26 as is required, since 14.06.05. Cotswold Spa Retirement Residence DS0000018644.V251147.R01.S.doc Version 5.0 Page 19 Because this was an unannounced inspection a questionnaire for the home and questionnaires for residents, relatives and health care professionals were not sent to the home prior to the visit and it was not possible to inform people of the availability of the inspector. Therefore the documents were left for distribution and completion after the inspection. The home’s questionnaire must be completed and returned to the Commission for Social Care Inspection. The responses from other people is voluntary but would be appreciated. Information obtained may be included in the report relating to the next inspection however names will not be included. The inspector asked the deputy to let people know that if they wished to speak to the inspector and had not had the opportunity, they could phone or make an appointment to meet and talk. The deputy was unable to provide full information regarding residents’ financial interests, as she had no involvement in this area. Access and records were maintained by the administrator and the manager. The deputy confirmed that supervision was provided. She received supervision from the manager and in turn she provided supervision for the care staff. Good records were being maintained for the sessions she conducted. Records of recent full fire safety checks and staff training were not available. However a care assistant had just completed training as a fire warden and was about to take up these duties regarding checks and training. The inspector discussed the maintenance of the log with him and undertook to send him some supporting information. Weekly tests of the fire alarms and automatic door closures were being carried out and service checks on the alarms and safety systems were undertaken with acceptable frequency. However a full Fire Risk Assessment for the home was not seen. The deputy confirmed that staff received training in moving and handling, health and safety, food hygiene and first aid although this could not be verified by the records. No other health and safety matters were assessed. Cotswold Spa Retirement Residence DS0000018644.V251147.R01.S.doc Version 5.0 Page 20 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X 2 2 Cotswold Spa Retirement Residence DS0000018644.V251147.R01.S.doc Version 5.0 Page 21 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 2 Standard 9 9 Regulation 13(2) 13(2) Requirement Medication records must be signed not ticked. Medication storage must meet the standard required by the British Pharmaceutical Society. Specifically the storage environment must be maintained between 23c & 25c degrees The staff should have ready access to a ‘whistle blowing policy and procedure’ and understand how to use it. 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. The person undertaking visits in accordance with regulation 26 must provide the Commission for Social Care Inspection with copies of the reports generated. Timescale for action 05/10/05 01/01/06 3 18 12 01/01/06 4 27 18 05/10/05 5 33 26 05/10/05 Cotswold Spa Retirement Residence DS0000018644.V251147.R01.S.doc Version 5.0 Page 22 6 37 17 The records specified in Schedule 05/10/05 4 of the regulations must be available at all times for inspection in the care home by any person authorised by the Commission to enter and inspect the care home. Fire safety checks and training must be undertaken in accordance with the advice and recommendations received from the Fire Authority and a Fire risk Assessment must be undertaken and maintained for the home. 05/10/05 7 38 12,13 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 14 Good Practice Recommendations The deputy should have some awareness of the management of residents’ money by the home. Cotswold Spa Retirement Residence DS0000018644.V251147.R01.S.doc Version 5.0 Page 23 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.V251147.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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