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Inspection on 06/12/05 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 6th December 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

The home offers a warm welcome to visitors at any time and the staff are kind and helpful. They relate well to the residents in the home and understand their needs and how they can help. Positive comments received in the questionnaire responses were; The deputy manager and staff are excellent and I feel confident they are looking after my relative as much as they can. The deputy and other trained staff are very helpful. The senior nurse works extremely hard to meet the needs of all the residents. She is conscientious and caring

What has improved since the last inspection?

Since the last inspection the deputy has received instruction in various management areas that enable her to cover the absence of the manager and meet the regulations more effectively. Eight tasks were identified during the previous inspection and six of these have been completed.

What the care home could do better:

There are issues relating to the control of infection, and availability of suitable activities and social events for the residents and maintenance of repairs and checks of fire safety systems that need to be addressed through effective staffing. Communication and interpersonal skills within the home and the community could be improved.

CARE HOMES FOR OLDER PEOPLE Cotswold Spa Retirement Residence Station Road Broadway Worcestershire WR12 7DE Lead Inspector Y South Unannounced Inspection 6th December 2005 10:00 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.V263181.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.V263181.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.V263181.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 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 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 accommodated. The care service is provided by Cotswold Spa Retirement Hotels Ltd, a member of Four Seasons Health Care, who leases 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 Lawrance. Cotswold Spa Retirement Residence DS0000018644.V263181.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two and a half hours from 10am until 12.30pm. The registered manager was absent attending a seminar so the inspector was ably assisted by the deputy Alice Antonio and the other staff on duty. The inspector also met four residents and undertook a partial tour of the building. The inspection focused on the requirements and recommendation that arose from the previous inspection and the key standards that were not assessed. A service questionnaire was left at the home in October for the manager to complete and return to the Commission for Social Care Inspection. This has been received. Questionnaires were also left to be distributed to residents, relatives and health care professionals. Ten responses were received by the Commission for Social Care Inspection and have been incorporated in this report where appropriate. What the service does well: What has improved since the last inspection? Since the last inspection the deputy has received instruction in various management areas that enable her to cover the absence of the manager and meet the regulations more effectively. Eight tasks were identified during the previous inspection and six of these have been completed. Cotswold Spa Retirement Residence DS0000018644.V263181.R01.S.doc Version 5.0 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.V263181.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.V263181.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): EVIDENCE: These standards were not assessed during this inspection. Cotswold Spa Retirement Residence DS0000018644.V263181.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): EVIDENCE: Compliance was checked with the two requirements that were made following the previous inspection. Both had been met. However one hand written entry in the MAR record was seen that had not been signed by the author and witness. It is essential that such entries are checked and accounted for. Cotswold Spa Retirement Residence DS0000018644.V263181.R01.S.doc Version 5.0 Page 10 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): 13 Links are maintained with the residents’ family and friends and where necessary personal monies are safely managed in the best interests of the residents, by the home. EVIDENCE: The deputy confirmed that visitors were welcome at any time each day and written information was available in the Statement of Purpose. Visitors could be received in the resident’s bedroom, in the quiet lounge or in the communal lounge. In the good weather the garden and patio were also available. Confirmation of this was received in the questionnaires that had been returned by the visitors. Only two people had personal money held for them in the home and managed on their behalf. It was observed that storage was acceptable and records had been maintained on computer by the receptionist. Receipts were kept for all expenditure. Cotswold Spa Retirement Residence DS0000018644.V263181.R01.S.doc Version 5.0 Page 11 There was no indication that receipts were given when money was given into the care of the home or that the computer information had been ‘backed up’. This will be checked later this week when the relevant people are available in the home. Advocacy services were not currently being used. However information was available and it was hoped that a speaker would be obtained in the near future to speak to the staff about the service they provided. Cotswold Spa Retirement Residence DS0000018644.V263181.R01.S.doc Version 5.0 Page 12 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 People have the advice and guidance they need to enable them to raise their concerns. Compliments and complaints are received and responded to. EVIDENCE: These standards were not assessed in full during this inspection. The record of complaints was not available at the time of the previous inspection. It was now readily available in the reception area and contained both complaints and compliments. The file contained four complaints and two compliments that had been received during the current year. The complaints concerned the quality of food on some days, communication with staff who were not fluent in English, low staff levels, poor laundry work, and some housekeeping and maintenance matters. The compliments had been concerned with the standard of care and management. A complaints procedure was available in the Statement of Purpose and displayed in the reception area. Nonetheless four questionnaire respondents recorded that they were unaware of the complaint procedure. Other concerns in the responses related to food, staffing levels and management. Cotswold Spa Retirement Residence DS0000018644.V263181.R01.S.doc Version 5.0 Page 13 A member of staff was able to locate the whistle blowing procedure and other related procedures in the reception area of the home. A policy and procedure should be available to guide and advise staff on how resident’s personal monies are managed. Especially if the people who usually manage this matter are unavailable. Cotswold Spa Retirement Residence DS0000018644.V263181.R01.S.doc Version 5.0 Page 14 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): 26 There are insufficient staff employed to manage the risks of cross infection. EVIDENCE: The home was generally clean and well maintained. However it was observed that some carpets were marked and in need of intensive cleaning, the floor area around the washing machines in the laundry needed to be cleaned and repaired. There was an area of damaged wall by two toilets and the ceiling in the hair salon had been damaged by a water leak. One resident, who had lived in the home for several years, had made a complaint about the heating in her bedroom. It appeared that this was an annual problem that required an effective and lasting solution. Supplementary heating was needed in some areas of the home. The hand basin in the laundry was difficult to reach because there was insufficient drying space for clothes on hangers. Cotswold Spa Retirement Residence DS0000018644.V263181.R01.S.doc Version 5.0 Page 15 Liquid soap, disposable towels and personal protective equipment were available everywhere except for liquid soap in the sluice. Staff confirmed that they had received training in infection control. The ancillary staff team was too small to provide complete cover for the home. When no staff were available to attend to the housework it fell to the care staff to do what was necessary. There was no designated laundry person employed so again this work had to be undertaken by the care staff if the domestic / housekeeper was unavailable. This staffing situation has serious implication related to the control of infection and has been remarked on by relatives and health care professionals. Cotswold Spa Retirement Residence DS0000018644.V263181.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 Insufficient staff are employed to meet the needs of the residents and the home. EVIDENCE: At the time of this inspection there were thirteen residents accommodated of whom ten needed nursing care. A duty roster was assessed. Shifts were identified with ‘E’ and ‘L’ for early and late. The shift starting and ending times were not given for the care staff as previously required. The duty roster indicated that care staffing levels were maintained at a minimum of one trained nurse and two care assistants and domestic staff were not always available. As previously stated on these occasions the care staff needed to undertake ancillary tasks as well as care duties. No one was employed specifically to involve residents in activities and social events and there was not a lot of time for the care assistants to undertake this aspect of care. Two residents who completed and returned questionnaires considered that the home did not provide suitable activities and it is clear from the comments received from relatives and health care professionals that they have concerns regarding the number of staff available. Cotswold Spa Retirement Residence DS0000018644.V263181.R01.S.doc Version 5.0 Page 17 Recruitment was currently underway for care staff and a maintenance person. It was acknowledged that recruitment can be difficult but sufficient staff must always be available to meet the needs of the residents and the home. There are a number of vacant places for residents at the moment and yet the service is under pressure. Staff need to be in post before more residents are admitted as the home must be able to meet the needs of residents at all times and recruitment takes time. An adequate sized team of permanent staff enables good relationships to develop, consistent care, cover and flexibility to be provided by people who are familiar to the home and residents. This cannot be provided so effectively by agency staff who are expensive but either they or staff from another Four Seasons home must be used if permanent staff are unavailable. The records were checked for the kitchen assistant who was appointed in the summer. An acceptable recruitment process had been used. The training file that was seen contained information of past courses. The deputy confirmed that staff had individual records in their files. There was no full team analysis of training or a training and development programme for the home. A training matrix was left with the deputy and a request that it be completed and returned to the Commission for Social Care Inspection with a training and development plan for the home. This has since been received and will be discussed with the manager in the near future. A good record had been maintained of the fire safety training that had been undertaken in November. All except four staff had participated. The deputy was required to ensure the four people received training during their first shift after the inspection. Cotswold Spa Retirement Residence DS0000018644.V263181.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): 35, 37, 38 The home has a capable manager but there is a need to develop more awareness of the affect of his management style on others, and for him to work towards improving communication and approachability. The personal monies of residents are managed appropriately but staff would benefit from a policy and procedure to advise and guide them. The risks of fire detection and response are not being fully addressed. EVIDENCE: The information provided by relatives and health care professionals raised some concerns regarding the managers’ leadership and management approach in the home. Theses have been brought to his attention. Cotswold Spa Retirement Residence DS0000018644.V263181.R01.S.doc Version 5.0 Page 19 The negative comments were balanced by an appreciation of the excellence of the staff who were described as hard work, caring and helpful. Standard 33 was not fully assessed as information was not available regarding the quality assurance system that was in use. Reports were available from the responsible individual following her monthly visits and copies are provided to the Commission for Social Care Inspection. Resident’s personal money was appropriately managed. All documents requested by the inspector were available. The member of staff who had undertaken training as the home’s fire warden was no longer employed and there was no record of the fire safety checks having been carried out since October. An immediate requirement was made that all systems be checked on the day of the inspection and the Commission for Social Care Inspection be notified when the task had been completed. The Commission for Social Care Inspection was informed two hours after the end of the inspection that the requirement had been met by a specialist who had arrived in the home. The routine monitoring of safety systems must not be allowed to lapse when there are staff changes. Cotswold Spa Retirement Residence DS0000018644.V263181.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 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 2 X 3 2 Cotswold Spa Retirement Residence DS0000018644.V263181.R01.S.doc Version 5.0 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP19 OP27 Regulation 23 18 Requirement The home must be maintained in good order and repairs effected as soon as possible. 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. Fire safety checks must be undertaken in accordance with the advice and recommendations received by the fire authority and a fire risk assessment must be undertaken for the home. Timescale for action 01/02/06 31/12/05 3 OP38 23 06/12/05 Cotswold Spa Retirement Residence DS0000018644.V263181.R01.S.doc Version 5.0 Page 22 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 OP18 Good Practice Recommendations There should be a policy and procedure that advises and guides staff in their responsibilities relating to service users’ monies and financial affairs. Including the raising and retaining of receipts for income and expenditure. There should be a training analysis of the full staff team and a training and development plan drawn up base on the analysis. 2 OP30 Cotswold Spa Retirement Residence DS0000018644.V263181.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.V263181.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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