Care Home: Cotswold Spa Retirement Residence

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What the care home does well Information is provided to help people decide if they wish to move into the home. In the main care plans have been reviewed so that staff have some information when supporting and assisting people to meet individuals health and personal care needs. All people in the home have access to other professionals such as the GP, tissue viability nurse, social workers and consultants so that they have access to advice to help individuals to remain healthy and well. The accommodation is spacious so people have a choice of areas where they can spend their time or see their visitors. People are encouraged to personalise their rooms with items that are familiar and hold `meaning` to individuals so that they live in an environment, which they prefer. Garden furniture has been provided so that people can enjoy the wild life and benefit from the fresh air to enhance their sense of well being. Families and friends are made welcome and can visit at any time. Staff recruitment procedures are robust to make certain that people recruited are not `banned` from working with vulnerable people which safeguards people living at this home from harm. The manager has shown they are passionate about `end of life` care planning and ensuring that people`s holistic needs are met at this important time of their lives. We are confident that the manager will stimulate staff practices in this area. What has improved since the last inspection? The care plans we looked showed that people are asked whether they prefer a female or male staff member to assist and support them with their personal care tasks. We saw a care plan to meet one person`s mental health difficulties so that staff have guidance to follow in meeting this persons specific needs. We did not see that the kitchen door is wedged open and or the placing of the food trolley outside the kitchen door. We were told that all relatives have received a copy of the complaints procedure so that they have the information should they wish to raise any complaints and or concerns. What the care home could do better: We have detailed above what has improved in the home but there are significant areas where there continue to be shortfalls as reported at the previous inspection. Therefore the manager must now prioritise open communication channels within the home, such as, surveys given to people who live in the home and or their representatives, staff and stakeholders. Also resident, relatives and staff meeting must now take place and be sustained. Either the person living at the home and or their representative should be consistently consulted about the care provided. This ensures that all parties are aware of the care being given, why, what this achieves and that person centred planning is weaved throughout practices within the home. Social stimulation and the provision of activities need improvement to make certain that it is meeting individual`s needs. This should include more opportunities for people to access the community and `one to one` stimulation. Care assistant staff levels must be reviewed and take into account the individual needs of each person who lives at the home so that there is sufficient staff on duty to meet peoples needs to keep them well, safe and meet their needs in a timely manner. Training for all staff must improve so that that it gives confidence to people living in the home that they are supported by knowledgeable and skilled staff who can meet their individual and collective needs at all times. Specific training in Dementia care should be considered to all staff so that the outcomes for people living at the home improve so that people`s sense of well being is promoted whilst keeping them safe. Specific training is needed for all staff in the Mental Capacity Act (MCA) and Deprivation of Liberty (DOLS). This will ensure all staff have the knowledge and skills to protect people from harm together with working in `the best interests` of individuals. Staff supervision must now be sustained. We are aware that staff are now beginning to receive supervision and a planner has been devised to help with the planning of supervision. Supervision provides staff have the opportunity of looking at their areas of practice and support is provided to staff with training and dealing with the people they care for. Key inspection report Care homes for older people Name: Address: Cotswold Spa Retirement Residence Station Road Broadway Worcestershire WR12 7DE     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Sally Seel     Date: 2 9 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 36 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 36 Information about the care home Name of care home: Address: Cotswold Spa Retirement Residence Station Road Broadway Worcestershire WR12 7DE 01386853523 01386852403 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): www.fshc.co.uk Cotswold Spa Retirement Hotels Limited (wholly owned subsidiary of Four Seasons Healthcare Ltd) Name of registered manager (if applicable) Type of registration: Number of places registered: care home 20 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is: 20 The registered person may provide the following category of service only: Care Home with Nursing (Code N); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 20, Physical disability (PD) 20 Date of last inspection Brief description of the care home 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 Care Homes for Older People Page 4 of 36 Over 65 20 0 0 20 1 1 0 1 2 0 0 9 Brief description of the care home possible for people who are less mobile. Cotswold Spa provides nursing care services for older people with accommodation to the three floors. There are 18 single bedrooms and one double occupancy bedroom. Access to each floor is gained by a central passenger lift or by using a staircase. There are two communal lounges and a communal dining room. Information regarding the service can be obtained from the Statement of Purpose and the Service Users Guide, that are available in the reception area. Copies of the Inspection reports are available on request from the person in charge. Cotswold Spa Retirement Hotels Ltd, a member of Four Seasons Health Care, who leases the building from a landlord, provides the care service. The registered manager has left and the current manager is to make an application to become registered with the Care Quality Commission. Interested parties are advised to make direct contact with the manager at Cotswold Spa to gain the up to date fes charged for living at the home. Care Homes for Older People Page 5 of 36 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The focus of inspections undertaken by the Care Quality Commission (CQC) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. The visit to the home was undertaken on the 29th January 2010 by one inspector over one full day and an Expert by Experience spent part of the day at Cotswold Spa. Mr. Patrick Reddin. An Expert by Experience is a person who, because of their shared experience of using services, and or ways of communicating, visits a home with an inspector to help them get a picture of what it is like to live in or use the service. The manager and staff on duty assisted us throughout. The manager and staff did not know that we were visiting on that day, when there were thirteen people living in the home. Information was gathered from speaking to and observing people who live at the home. Two people were case tracked and other peoples care records were briefly looked at. Case tracking involves discovering individuals experiences of living Care Homes for Older People Page 6 of 36 at the home by meeting or observing them, looking at medication and care records and reviewing areas of the home relevant to these people, in order to focus on outcomes. Comments gained from staff working at the home on the day we visited where appropriate have been included in this report. Staff files, training records, maintenance and complaints records were also reviewed. Reports about accidents and incidents in the home were reviewed in the planning of this visit. The manager completed an Annual Quality Assurance Assessment (AQAA) earlier this year. This told us how well the management team think they are performing and gave us some information about staff and people who live there, improvements and plans for further improvements, which we have taken into consideration. We would like this opportunity of thanking people, who live in this home, the manager and all staff for assisting us with this inspection and making us feel welcome. Care Homes for Older People Page 7 of 36 What the care home does well: What has improved since the last inspection? What they could do better: We have detailed above what has improved in the home but there are significant areas where there continue to be shortfalls as reported at the previous inspection. Therefore the manager must now prioritise open communication channels within the home, such Care Homes for Older People Page 8 of 36 as, surveys given to people who live in the home and or their representatives, staff and stakeholders. Also resident, relatives and staff meeting must now take place and be sustained. Either the person living at the home and or their representative should be consistently consulted about the care provided. This ensures that all parties are aware of the care being given, why, what this achieves and that person centred planning is weaved throughout practices within the home. Social stimulation and the provision of activities need improvement to make certain that it is meeting individuals needs. This should include more opportunities for people to access the community and one to one stimulation. Care assistant staff levels must be reviewed and take into account the individual needs of each person who lives at the home so that there is sufficient staff on duty to meet peoples needs to keep them well, safe and meet their needs in a timely manner. Training for all staff must improve so that that it gives confidence to people living in the home that they are supported by knowledgeable and skilled staff who can meet their individual and collective needs at all times. Specific training in Dementia care should be considered to all staff so that the outcomes for people living at the home improve so that peoples sense of well being is promoted whilst keeping them safe. Specific training is needed for all staff in the Mental Capacity Act (MCA) and Deprivation of Liberty (DOLS). This will ensure all staff have the knowledge and skills to protect people from harm together with working in the best interests of individuals. Staff supervision must now be sustained. We are aware that staff are now beginning to receive supervision and a planner has been devised to help with the planning of supervision. Supervision provides staff have the opportunity of looking at their areas of practice and support is provided to staff with training and dealing with the people they care for. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 36 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 36 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Admissions are not made to the home until a needs assessment has been undertaken by the manager, this ensures that the home is confident that all assessed care needs of the individual can be fully met. All information about the home should be reviewed to make sure all details are up to date and made available in different formats. Evidence: In the reception area of the home we found a variety of information which was provided within the statement of purpose about the home, what it would be like to live there, staffing and complaints procedure. This needs some minor improvements to ensure that the information given is fully updated and does not mislead people who may be considering living at the home. Also in the reception area we saw a brochure about the home where the words are illustrated with some photographs so that people can be aided with visual clues to help them to decide whether the home is the right one for them. We also saw that it says Care Homes for Older People Page 11 of 36 Evidence: that the homes brochure contains information about the accommodation, care, facilities, choice of food, types of stay, admission and fees. At the previous inspection it was recommended that the fees charged to people for living at the home should be documented in the service user guide and the brochure confirmed that this is the case. This will further help people in assessing their individual financial situations and is required to meet the regulation. It was unclear as to whether the information we saw is made readily available in different formats, such as, larger print, audio visual and audio tape from reading the brochures and other information so we therefore recommend that it is so it is made accessible to all people regardless of their reading and sight abilities. We were told that people who may be considering living at the home are able to come for visits. This is confirmed within the brochure, Prior to admission each new resident is encouraged to visit the home to satisfy themselves that the ambience is to their liking. Nursing care and support is provided within the home for up to twenty people. At the time of our inspection we were told that there are thirteen people living at the home whose ages ranged from 49 years old to 89 years old. The brochure tells us, Our Home manager will also wish to discuss the personal preferences of each prospective resident and whatever care and other needs they may have. One person who has recently come to live at the home are younger than the other people who live in the home. However, we were assured that this persons range of needs are being appropriately met. We were also told that this persons family are happy that their relative has come to live at the home as it is close for them to continue to visit. We were unable to look at this persons records in any depth to see if their needs were fully assessed prior to them coming to live at the home. This was due to the manager requiring these on the day we visited and therefore we are unable to make any comments about this persons admission into the home. However, we did look at two peoples care records and saw that each persons full range of needs are considered before they come to live at the home. This is supported by an assessment by a social worker or other professional. We saw that the assessment form used by the manager gives details of all their personal care needs as per the National Minimum Standards. It highlights the main concerns relating to that person, as well as their dietary preferences. We found that some areas of care planning, social activities Care Homes for Older People Page 12 of 36 Evidence: offered, staff training and running of the home require some improvements which will be further discussed throughout this report. These improvements are important to help the manager to be able to clearly state to people that their specific needs will be met by the homes facilities, staffing numbers, qualifications, skills and knowledge before people come to live at the home. We were told that respite care is provided at the home for people who may wish to spend short periods of time at the home, sometimes to give their carers a break and themselves. However, intermediate or rehabilitative care is not provided at this home. Care Homes for Older People Page 13 of 36 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each individual has a care plan that inform staff of how to meet peoples health, psychological and personal care needs but the practice of involving each person and or their representatives in the development and review of the plan is variable. Some improvements need to be made in ensuring that people are assisted at times when they need this. Evidence: On the day we visited we saw, were told and read in care plans that there are a range of different people with varied needs living at the home, including people with dementia, people with very high physical and medical needs and people with visual impairments. To help staff to meet each persons specific needs all people living in the home have a plan of care that is based on the information gained prior to coming to live at the home and this is reviewed on a regular basis. We were told that each person is assigned a key worker, someone who takes special interest in the person, liaising with family and ensuring all needs are ascertained and met. We looked at the key workers recording and found that for a period of time this Care Homes for Older People Page 14 of 36 Evidence: process was not working. However, on discussing this with the manager they acknowledged that they have just assigned each person with a key worker. Therefore people living in the home will benefit from having a member of staff that gets to know them really well. Having a dedicated member of staff for each person also helps when people may need some reassurance and or want to raise some concerns. As already mentioned we looked at two peoples care plans and found that they covered their physical care needs, their social and emotional care, and their health care. Under different headings peoples needs are recorded with instructions for staff about what actions to take. Peoples personal details are recorded and monitoring records such as weight, pressure areas and nutrition. Care plans also include health professionals visits, daily records, and medical actions or events. In the AQAA it confirms that, Provide a dedicated care team, under supervision of qualified nursing staff, to support every resident to achieve their choice and preference in care. However, the care records we looked at did not consistently suggest that people and or their representatives were being fully involved with the care planning process. The care plans we saw were only signed by the nurse who had completed them and an area that was lacking in the care plans highlighted that person centred planning was not always taking place. For example, peoples preferences and choices in regard to their daily routines, getting up from bed in the morning and going to bed in the evening should be fully explored with each person. It is suggested that by making sure that care plans are user friendly would help in engaging people in having their say on how they prefer their care and support to be delivered. It is acknowledged that some people may not wish to or are unable to contribute to the process but efforts should be made to ensure that the plan of care is discussed and agreed with the individual. On a more positive note we did find that the choices of whether people would like a female and or male member of staff to assist and support them with personal care tasks were highlighted in the care plans that we saw. This is an improvement that has been made since we last inspected the home. In some care plans for personal care we saw in one what the person was able to do for themselves to prompt staff about helping people to retain their levels of independence. We also saw what one person likes to wear but this was not clearly recorded in another persons plan which once again makes the recording in care plans variable in relation to being person centred. The care plans are based on assessments of risk and the activities of daily living and Care Homes for Older People Page 15 of 36 Evidence: where a potential risk has been identified; the action to be taken to reduce the risk was recorded. One care plan we looked at identified a person was at risk of developing pressure areas, a plan had been implemented for the use of specialist equipment, continence care and personal hygiene. On another care plan and risk assessment we saw that the person had decreased walking abilities. We therefore saw instructions for staff to follow. Positively these included the name of the hoist to be used, sling loop colours to reflect which part of the persons body these should be placed and numbers together with the number of staff who would be required to maintain this persons safety at all times. The people living and working at the home appear to have developed good relationships with each other as some people living in the home called staff by their name. However, we observed staff to be very busy and on one shift there were two male members of staff with one female member of staff. This meant that the female member of staff was covering a lot of the work due to people who lived in the home being female. This did concern us and we raised this with the manager who was aware of this factor. Staffing numbers will be further discussed within this report. The Expert provided us with their observations:I visited the lounge area which had ten chairs available in the seating area. I spoke to five residents who were watching TV. No staff came into this area when I was there and one lady mentioned to me that she needed the toilet but had no means to call staff apart from shouting. She said There was a switch on the wall which no-one can reach. It was observed that there was no other means of attracting staff attention in the room. After speaking to a number of residents it was apparent that when in their rooms attracting staff via intercoms or bells takes a long time. I have to wait half an hour to go to the toilet. Rang bell and they came an hour later. It is suggested that the manager reviews staffing numbers and whether all people living in the home regardless of their abilities are able to call for assistance at any given time. This is important due to the layout of the home and dependency of some of the people who live in this home. We observed that people were well dressed for the time of year to reflect their personalities. Daily records told us that people were having baths and or showers fully Care Homes for Older People Page 16 of 36 Evidence: assisted and supported by staff in respectful and dignified manners. The Expert said, From my observations. Their individual needs in terms of being kept warm, clean clothing and well presented were being achieved. We audited with a member of staff two peoples medications and found that these two people were receiving their medications as prescribed. The audit process showed that the Medicine Administration Record (MAR) charts had been signed when the medication had been administered. We also found that there were no signature gaps and or inappropriately used abbreviations on the MAR charts. One area of medication that now requires improving is to make certain all people who are prescribed when required medication have their own individual written protocols so that staff know how and when to give these type of medications. We found that the storage area and trolley where the peoples medication was kept was clean and well organised. We found that there were no excessive stocks of medication and the manager had recently completed their own audits of medications. These factors would mean that there was less risk of errors and consequently less risk of people receiving the wrong medicines. We found that all medication is handled and administered by the trained nursing staff. We were advised that there is always a trained nurse on each shift and the staffing rotas confirmed this to be the case. One area that we were unclear about is how and who assesses the nurses for their competency to handle and administer medication safely on an ongoing basis. We will however inspect this area when we next undertake an inspection at the home. Care Homes for Older People Page 17 of 36 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Generally staff are aware of the need to support people with daily life and social activities but are often too busy reacting to meeting peoples functional duties. Improvements are underway so that people are consulted and listened to regarding the choice of daily activities, the effectiveness of the changes will be determined over time, when the social stimulation needs of people are fully met. Evidence: The Expert reported:The Manager mentioned that they had been trying to recruit a Social Activities Coordinator for some time without success. The position has been vacant since Sept 2009. This is a part time role working ten hours a week. There was a large sheet of paper on the wall listing forthcoming events such as Valentines Day and St Patricks Day. No therapeutic and social stimulation or activities for residents were observed during my visit. Everyone was either in front of the TV in the lounge or in their rooms. There was an Activities Room available for both residents and staff to use. I observed that only staff were using it for rest breaks and eating lunch. Care Homes for Older People Page 18 of 36 Evidence: The majority of stimulation observed such as doing crosswords, reading papers etc was generated by residents themselves. Otherwise it was generally watching TV either in the lounge or in their rooms. There was one example of a resident being supplied with Book tapes by the Manager on a weekly basis from the local library. We were advised by the manager that they are looking to improve the range of activities offered to people. This is being achieved by asking people for their suggestions and a long list was well underway which we found on the lounge door. We were also shown an activity planner for the month of November 2009 which listed activities that had taken place in one week as, poems and short stories, jigsaws, library and sweet shop, hand massages and manicures, sing a long with staff, skittles, flower arranging demonstration, lets go to the movies, coffee morning and letter writing service, personal shopping lists, chit chat and coffee morning and jigsaws and games. The manager also confirmed that people experienced a Burns night with haggis on the menu, war time day of events to take people back in time. Animals had visited the home which we were told by staff that people really enjoyed and participated in. It was unclear as to whether people have been supported to access activities in the community and therefore improvements must now be made in this area. We saw that in the reception area there is a notice which informs people of the regular visits from the church. This shows that peoples religious and spiritual needs are being considered so that people can be supported to follow their own faith. It was positive to hear that staff also recognised that activities needed to be improved for people. It was agreed that by having a range of activities for people to experience would enhance their quality of lives. This must now happen as we cannot be certain through our conversations with staff and observations that people are even gaining adequate outcomes in relation to social activities and stimulation. It should also be acknowledged that on the day we visited staff did not have the time to complete any activities with people due to their functional duties. Therefore any social stimulation, such as, staff interaction with people was mostly undertaken within the functional operation of assisting people with their personal care tasks. This now requires to be broadened out and it is suggested that by ensuring that people do now have dedicated key workers within their roles they could assist people with their life stories and so on. This will help in many ways as staff will learn about peoples backgrounds and past interests. Care Homes for Older People Page 19 of 36 Evidence: The manager in the AQAA advises us of what the home does well in relation to meeting peoples social wellbeing as:We have put in place a mobile shop which is open weekly. We collect talking books and large font books which we change regularly, from our local Library. We are about to issue the first publication of our in house magazine Chatterbox we have an editor and a roving reporter and we encourage contributions from residents, staff and others. We have established a group of residents, relatives, friends and staff to form a residents group first meeting due in December 09. We offer a letter writing facility and a personal shopping facility staffing related. A qualified aromatherapist masseuse offers hand and body massage and has offered to train staff in some basic massage techniques. These will take place in the new Therapy and Hairdressing salon to be opened in December 09. Staff also offer manicure and pedicure services. It should be acknowledged due to the change in management of the home together with the manager being away from the home for a period of time it is suggested that the effectiveness of the changes will be determined over a period of time. Therefore we cannot confirm that the above is being done really well at this time. Therefore we will focus upon the experiences and outcomes of peoples daily life within the home at the next inspection. The expert provided their report in relation to meals:Before eating, I went into the kitchen and spoke to the Chef who was from an agency. The lunch was being prepared with fresh ingredients and of good quality. I had lunch with five residents; the dining room was set for nine places. The food tasted was good and portions for each person were based on their usual requirements. Where appropriate, food was mashed individually when served. There was a varied Care Homes for Older People Page 20 of 36 Evidence: menu with two choices for each course. It was quiet during lunch with staff communication reactive rather than proactive. Staff knew residents names and there were some examples of residents knowing staff names. It was apparent from the majority of residents that they liked the home, enjoyed the food. Some of the comments made were, my son chose this home, I love it, beautiful place. Staff are kind. Staff are pretty good, I have breakfast here, dont see much of them. Food is not too bad at all, I have no complaints, I have not had dinner in the dining room. Staff are all friendly. The food is very good, I am here in my room all the time, I prefer that. Some staff are exceedingly kind, some are not. Comments from a relative, Some of them are slapdash, they try and ram the food in, by and large staff are caring, rang bell and they came an hour later, I rang several times with no response, spoke to the manager but no improvement, food varies a bit but breakfast first class. The home operates a rotational menu for all meals served and we saw that the menu is on display in the dining room on the dresser. The menus we were shown confirmed that people have their main meal of the day at lunchtime. From looking at the menus the meals looked varied particularly at breakfast time as we saw choices ranging from different types of cereals to a cooked breakfast. Lunchtime meals were, soup of the day is always served, turkey escalope or plaice, apple cream or ice cream. Cottage pie or sweet and sour pork, rice pudding or ice cream. Lamb casserole or chicken pie, fruit crumble or ice cream. Evening meals were soup and sandwiches, jacket potato with various fillings and choice of sweets. Corned beef hash, fish pie, macaroni cheese, baked beans on toast, creamed mushrooms on toast. Staff told us that drinks and biscuits were offered throughout the day and we observed this to be the case. Comments from staff about the meals:Food is very delicious. There is a good variety. Meals are good. Care Homes for Older People Page 21 of 36 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has a complaints procedure that is displayed in the home; some amendments are required to ensure that people have the correct contact details of other agencies should they wish to contact them. Staff showed awareness and knowledge in relation to recognising and reporting any observations of abuse. Evidence: We saw copies of the complaint procedure which is displayed in the reception area and can be found in the information brochures about the home. All information that tells people about how to complain should be amended to ensure that our details are correct should anyone wish to contact the Care Quality Commission (CQC). We looked at the complaints log and found that where complaints have been made to the home these have been responded to appropriately in a timely manner. However, the response to all complaints should be in the log book so that these can be made available. Some complaints that had been raised by a family member to CQC and the home had been upheld and action taken to resolve issues highlighted. The annual quality assurance assessment tells us, Provide a clear and accessible complaints procedure and policy to residents, families, staff and key others. Immediate response to complaints both verbal and written, with regular feedback through out the procedure until resolution or agreement. We were told that there is now a suggestions box and a comments book is in the reception area of the home. Care Homes for Older People Page 22 of 36 Evidence: The annual quality assurance assessment also tells us: Provide a robust induction programme including evidencing of knowledge about whistle blowing, bullying, harassment..... The manager must remeber to complete the number of safeguarding referrals that have been made in the appropriate section of the AQAA as this was left blank. We spoke to several members of staff during our visit. All of the staff we spoke to were knowledgeable about the signs of abuse and what action to take if they have concerns. In the main the staff training matrix confirms that nearly all staff have received training in 2009 relation to the Protection of Vulnerable Adults (POVA). It would be good practice for the service to provide staff training and awareness of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DOLS). This examines how risk assessments and decisions to restrict someones liberty such as movement, leaving the home or making decisions for themselves should be done to ensure that their liberty is not denied Care Homes for Older People Page 23 of 36 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service live in a home that is comfortable, well maintained and meets their needs. Evidence: Cotswold Spa is located within the village of Broadway and has been converted for use as a care home. There is a driveway but this is rather steep so people with physical disabilities would need to be brought to the front door by some form of transport. There is also a rear garden which is enclosed but part of the garden is not suitable to be used as it steeply rises to an orchard. There is a table and chairs for people to sit out in the garden as they choose so that they benefit from some fresh air and can watch the wildlife. However, there is a safety issue in the garden which needs some attention to make sure peoples safety is assured and was noticed by the Expert:One observation, the garden area had a patio with a central area of stones. This area had a raised kerb around it which could easily trip a resident. The Expert also reported:Cotswold Spa is a small home with 19 rooms on three floors, one of which is a double. There is a superstitious element as there is no number 13! It was bright, well maintained, clean, and comfortable. No odours were apparent in the majority of the Care Homes for Older People Page 24 of 36 Evidence: home although there were strong odours in two empty bedrooms which were cleaned and ready for new residents. A partial tour of the home was undertaken with the manager, we looked at communal areas and bedrooms and bathing facilities. We were told that there is an ongoing redecoration programme in place and the manager is ensuring that homely touches remain within this programme. The atmosphere was friendly and pleasant and there were no unpleasant odours apart from those in the bedrooms that are currently vacant as reported by the Expert. The AQAA confirms the improvements planned for the next twelve months are:Further appropriate decoration Update TV Purchase of a covered gazebo. There are a number of smaller seating areas throughout the home where people can choose to sit on their own or with visitors, such as, the reception area, a quieter lounge which overlooks the garden area and a small activity room that. As we have mentioned earlier in this report we only saw staff using this room on the day we visited. It is also acknowledged that the quieter lounge was also not used and this may be connected with it being too cold and or further away from the main lounge for people to walk to as some staff told us. All of these areas had comfy seating and homely touches. Chairs had been arranged to promote social interaction as far as possible. There are assisted bathing facilities together with ensuite facilities in peoples own rooms, which meet the needs of the people who live there. In the AQAA it confirms that bathrooms could now be upgraded. We saw that infection control practices are upheld in these areas, liquid soap and hand towel dispensers are provided. Although all staff must receive infection control training as we found some gaps highlighted on the training matrix so that people living in the home can be confident that they will be protected from any risk of infections or cross contamination. Bedrooms seen were personalised and reflected individual tastes, gender and cultural preferences. People are encouraged to bring in their own possessions in order to have familiar items around them to make their rooms as homely as possible. We also saw that people had specialist beds and mattresses demonstrating that peoples physical needs are being met within their home. We saw the hairdressing room that is fully equipped for people to use but the ceiling area needs to be repaired before this can happen and the manager told us that this is Care Homes for Older People Page 25 of 36 Evidence: in hand. The manager also told us that other therapies can take place in this room, such as, hand and nail care, aromatherapy etc. There is a passenger lift for people to use to access all floors together with a staircase. Care Homes for Older People Page 26 of 36 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager must review staffing numbers so that people living in the home are always supported by suitably trained staff in the right numbers to meet their needs. The manager is aware that there are some gaps in the training programme and plans to deal with this so that people using the service can be confident that they have the skills needed to meet their needs. Evidence: In addition to care and nursing staff the home employs an administrator, housekeeper, domestics, maintenance person and cooks to provide support to people using the home. On the day we visited there was a nurse and three care staff on duty. We were told by the manager that sometimes there are four care staff on duty which helps with providing people with some stimulation as there is no activity coordinator at the present time. The staffing rotas confirmed what we saw in relation to the staffing levels apart from on one occasion where there were only two care staff and a nurse on duty. This is potentially unsafe and may place people and staff at risk. It also puts into question staffs ability to effectively meet each persons needs. As mentioned previously in this report staff were seen to be very busy and some people had to wait for assistance. We also saw that very often care staff are working long hours, for example, 8:00am until 08:00pm, which is tiring for staff who then may not be able to meet the demands of the people living in the home. Therefore staffing Care Homes for Older People Page 27 of 36 Evidence: levels should be reviewed to make certain the staffing ratios meet the dependency needs of each person who lives at Cotswold Spa. It is acknowledged that the home does have vacancies and would be concerned if further people came to live at the home without staffing levels being reviewed. It is acknowledged that the manager confirms in the AQAA the plans for improvements over the next twelve months:The appointment of a Deputy Manager, Full time RGN, PAL, Kitchen assistant and our own bank of carers and nurses to provide continuity of care. We examined a number of staff records and this confirmed that all checks are carried out to ensure that they are suitable to work with vulnerable people. The AQAA confirms that twenty four staff have left the home in the last twelve months with three of those being dismissed. We were advised by the acting manager that recruitment is ongoing. All nursing staff have had their PIN number checked with the Nursing and Midwifery Council to ensure that they are registered to nurse. In the AQAA it confirms that only three members of staff who work at the home have completed National Vocational Qualification Level 2. It is recommended that at least 50 per cent of staff have this qualification so that a knowledgeable and skilled workforce can meet peoples needs individually and collectively. We looked at how staff training is managed and what training staff have completed. However, it was not possible to exactly establish the training that has been completed for each member of staff as the manager had to develop a new training matrix. The matrix does have training gaps but we are confident that the manager will now ensure that all staff receives mandatory training. It is imperative that staff are adequately skilled, trained and competent to do their job. All staff must receive training and regular updates in all core topics e.g. fire safety, first aid, health and safety, moving and handling, infection control, COSHH, and specialist topics e.g. MCA and DOLS dementia etc, to ensure that residents needs are fully met and they are in safe hands. It is now required that all staff must receive training and regular updates in the core topic areas and any specialist areas relating to the service provision. Care Homes for Older People Page 28 of 36 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is striving to provide a person centred service, which people benefit from and their financial interests are safeguarded. Management systems, procedures and staff training need to develop, so that peoples health and wellbeing are proactively protected. Evidence: Since the last key inspection the registered manager has left the home. Mrs. Janie Ware has now been recruited as the manager and they are a registered nurse and have completed the Registered Managers Award (RMA). Mrs. Wares other qualifications are Diploma in Management (Level 5), Cert Ed (Higher/Further Adult Education) Education, Assessors Award and Internal Verifiers Award. Mrs. Ware is well qualified and will be making an application to become the registered manager in the near future. There are some practices and records within the home which informed us that they had been a lapse, some of which have been discussed throughout this report. It Care Homes for Older People Page 29 of 36 Evidence: became unclear as to when all staff had last received supervision session, how staff training had been planned, staff and resident meetings. Therefore the manager has to restart these so that people living in the home can be confident that the home is being run in their best interests. The AQAA showed some insight and recognition into what the manager needs to do to improve the service provided how they planned to achieved this. The manager must be careful with the information that was provided to us, particularly in the, Our evidence to show that we do it well, section of the AQAA. As this is an area we would expect to see reflected in the practices and procedures when we undertake an inspection. For example, staff supervisions, staff meeting residents and relatives meetings minutes. As the manager is aware that staff supervisions, training, staff and resident meetings have lapsed although as we have acknowledged the manager is starting afresh and showed us the planners for staff training and supervision that have put in place. Therefore we will not be able to assess the effectiveness of these until they have been consistently sustained over a period of time. Another area that we could not identify has been sustained is the frequency of visits to the home by a representative of the organisation. The manager did provide us with two recent visits that had been made but the manager had not seen these reports and they were not filed at the home for us to inspect. It is important that these visits are completed regularly each month and are available at the home at times of inspection. It is also particularly important that the manager has seen the reports as they look at the quality of the service offered and how well the home is running to reflect what needs to improve and what is working well. These reports should help the manager in the running of the home to improve the quality of care provided. We did not see any surveys that have been sent to people who live there and their relatives to ask them what they thought about the service provided. We also sent some surveys to the home for completion and we were told that the surveys still need to be given to people. On the day of our visit the manager was observed by the Expert to give a survey to one person to complete. Therefore we are not confident that people are continually having their say in respect of the running of the home. As confirmed in the section, Complaints and Protection, there is a robust system in place for recording personal money, which should ensure that it can be held safely at the home, on behalf of the people who live there. Records of servicing, tests and maintenance in respect of health and safety for utilities, appliances and equipment such as electricity, fire; emergency lighting and hoists are well maintained and this should ensure they are safe to use. Care Homes for Older People Page 30 of 36 Evidence: Staff receive fire training and complete fire drills to ensure they have the knowledge to act appropriately to safeguard people in the event of a fire As stated earlier in this report all staff training now needs to be sustained so that people can be confident that staff have all the training they need to meet peoples needs. Also our observations are that the staffing levels need to be reviewed to ensure that there are enough staff available on each shift to help people in the way they prefer in a timely way. This will also make certain people are gaining good experiences and are in safe hands at all times. It is clear from our visit that many areas in the service now require improvement, some of which remain outstanding from the previous inspection visit. Therefore the manager now needs time to sustain improvements and work on other areas that still need improving. We have provided examples throughout this report. This should ensure that people living in this home are receiving person centred care and support. This means promoting individuals diverse needs in personal and health care, mental health, physical needs together with social stimulation including personalised activities. Care Homes for Older People Page 31 of 36 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 32 of 36 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 8 12 All staff who provide care to 12/03/2010 people who live at the home must have the knowledge, skills and competency required to meet individuals needs together with their planned care. This will make certain that individuals health and welfare is not placed at risk by staff practices. 2 28 18 The homes staffing levels 12/03/2010 must be reviewed. This must be in line with individuals dependency levels and available for inspection. This will ensure that people living in the home receive care in an appropriate and timely manner that meets their needs. 3 33 26 The Provider or their representative must ensure monthly unannounced visits to the service are 12/03/2010 Care Homes for Older People Page 33 of 36 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action consistently sustained in accordance with this Regulation and the outcomes of this are shared with the manager. This will ensure that the quality of the service being provided to the people who live in the home is fully monitored. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 The registered person should ensure the statement of purpose and service users guide are made available in accessible formats to suit individuals needs, such as, large print, pictorial and audio visual. Written information in the statement of purpose and service user guide should be updated to reflect factual details. This will make sure that any changes in the service are detailed so that people can make an informed decision about the home. Care plans should provide details about personal preferences so that people receive care in a way that they prefer. Consideration should be made to all staff receiving end of life care training that is appropriate to their position to ensure peoples and relatives needs are met in an appropriate manner. It would be good practice to gather and further develop a life story about a person during their assessment and after they have moved in, which would help personalise the care and support they receive and improve their quality of life. 2 1 3 7 4 11 5 12 Care Homes for Older People Page 34 of 36 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 6 12 Show clear links between activity opportunities and peoples agreed goals and care plans. Doing this will help people achieve their goals and improve their quality of life. People should have opportunities to access the local community with staff on a regular basis so that they are supported to lead interesting and meaningful lives. Staff should not work long days so that they are not tired and are able to meet the demands of the people using the service. Staff should receive National Vocational Qualification Level 2 (NVQ) training in care to ensure they have the knowledge and skills to care for people. The manager must take a proactive approach in continuing to develop the staff training and development programme and keep clear records of this to provide evidence of the training staff have achieved together with any refreshers needed. The manager must continue to progress their application to be registered manager of the home with CQC to demonstrate their commitment to providing commitment and stability for the benefit of residents and staff. Consideration should be given to identifying ways that communication within the home can be improved, such as, resident and staff meetings and the completion of surveys, so that people living there will benefit You should ensure that the system for evaluating the quality of the services at the care home is fully implemented, and a written report of the outcomes made available to all interested parties. This is so that it can be seen that the views of people who use the service underpin the way in which it is reviewed and developed. Staff should be clear on their roles, be supervised at least six times a year, and have meaningful regular appraisals of their knowledge, performance, and development needs. We recommend audits of safe working practices and quality of care as well as observed practice is used to confirm competences. 7 13 8 27 9 28 10 30 11 31 12 32 13 33 14 36 Care Homes for Older People Page 35 of 36 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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