We carried out a review of the data available to us about Cotleigh on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Cotleigh, you can give feedback on this service.
We found the following examples of good practice
Relatives and friends were encouraged to keep in contact with their loved ones via telephone and video calls. A visiting pod had been erected outside to facilitate face to face visits.
The premises were clean and well maintained. The home was undergoing a refurbishment programme to update the premises. For example, carpets were being replaced with laminate flooring.
Some people residing at Cotleigh were living with dementia and liked to walk with purpose along the corridors and in communal areas. Staff supported people to keep apart as much as possible to try and maintain safe social distancing. Frequent touch points, such as handrails were regularly cleaned.
All staff had received training in infection prevention and control and their competency in this area was regularly checked by managers. Staff were seen to be following correct practice in this area.
All people living and working at Cotleigh had been offered a vaccine and were regularly tested for COVID-19 in line with government guidance.
Cotleigh is a residential care home that provides accommodation and personal care for adults with a range of care and support needs, including adults who are living with dementia. The home can accommodate up to 62 people in one adapted building over two floors. At the time of this inspection there were 54 people using the service.
People’s experience of using this service and what we found
People were cared for by staff who treated them with kindness, dignity and respect. Staff knew people well and they were responsive to people’s individual needs. People and their relatives described staff as “lovely” and “kind”. Staff welcomed people’s relatives into the home, to support people to maintain important relationships.
People were supported to take part in a range of activities, to help them remain meaningfully occupied. Staff encouraged people living at Cotleigh to develop positive relationships with each other. People told us they had made friends within the home and we observed people enjoyed spending time with each other.
Staff were knowledgeable about people’s needs. The service used an electronic care planning system which supported staff to regularly review the care and support people needed. Staff supported people to access other health and social care professionals and they acted on any advice they were given. People were supported to eat and drink enough, and people’s special dietary requirements were catered for.
People were happy with the quality of the care they received. People felt safe and they were protected from the risk of abuse. Risks to people were assessed and staff were knowledgeable about how to support people to remain safe. People were protected from the spread of infection and they received their medicines as prescribed.
There were enough staff to keep people safe and meet their needs in a timely manner. People were supported by staff who were appropriately trained and supervised. Staff had the skills they needed to care for people effectively. All staff felt well-supported by the registered manager and the morale of the staff team was positive.
Staff encouraged people to make their own decisions and they obtained consent from people before care was delivered. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. The policies and systems in the service supported this practice.
The home was managed by an experienced registered manager. People, their relatives and staff told us the service was organised and well-run. The registered manager used suitable systems to monitor the quality and safety of the service. People, their relatives and staff had opportunities to provide feedback about the service and share their ideas about how it could be improved. People knew how to complain if they had any concerns about their care.
For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 3 July 2017).
Why we inspected
This was a planned inspection based on the previous rating.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
There was a manager at the service who was registered with CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.
Our last inspection at Cotleigh took place on 5 July 2016. We found a breach in the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in regard to regulation 18; Staffing. The registered provider sent an action plan detailing how they were going to make improvements. At this inspection we checked improvements the registered provider had made. We found sufficient improvements had been made to meet the requirements of Regulation 18: Staffing, as sufficient levels of staff were provided to meet people’s needs in a timely way.
This inspection took place on 2 June 2017 and was unannounced. This meant the people who lived at Cotleigh and the staff who worked there did not know we were coming. On the day of our inspection there were 59 people living at Cotleigh.
People living at Cotleigh and their relatives spoken with said Cotleigh was a happy and safe home.
We found systems were in place to make sure people received their medicines safely so their health was looked after. However, we observed one occasion where safe procedures were not adhered to. This was rectified during our inspection.
Staff recruitment procedures ensured people’s safety was promoted.
Sufficient numbers of staff were provided to meet people’s needs.
Staff were provided with relevant training so they had the skills they needed to undertake their role.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the registered provider’s policies and systems supported this practice.
People had access to a range of health care professionals to help maintain their health. A varied diet was provided, which took into account dietary needs and preferences so people’s health was promoted and choices could be respected.
Staff knew people well and positive, caring relationships had been developed. People were encouraged to express their views and they were involved in decisions about their care. People’s privacy and dignity was respected and promoted. Staff understood how to support people in a sensitive way.
A programme of activities was in place so people were provided with a range of leisure opportunities.
People said they could speak with staff if they had any worries or concerns and they would be listened to.
There were systems in place to monitor and improve the quality of the service provided. Regular checks and audits were undertaken to make sure full and safe procedures were adhered to.
There was a manager at the service who was registered with CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.
Our last inspection at Cotleigh took place on 15 September 2014. The home was found to be meeting the requirements of the regulations we inspected at that time.
This inspection took place on 5 July 2016 and was unannounced. This meant the people who lived at Cotleigh and the staff who worked there did not know we were coming. On the day of our inspection there were 60 people living at Cotleigh.
People spoken with were mostly positive about their experience of living at Cotleigh. They told us they felt safe and they liked the staff.
Relatives spoken with felt at times, insufficient numbers of staff were provided as they were not always visible around the home. Relatives had no concerns regarding the staff and no complaints about the home. We found sufficient staff were not always present to provide the support people needed.
Healthcare professionals spoken with told us they had no concerns about Cotleigh and felt people were well cared for.
We found systems were in place to make sure people received their medicines safely.
Staff recruitment procedures were thorough and ensured people’s safety was promoted.
Staff were provided with relevant induction and training to make sure they had the right skills and knowledge for their role. Staff understood their role and what was expected of them. They told us they liked their jobs, worked well as a team and were well supported by the registered manager.
The service followed the requirements of the Mental Capacity Act 2005 (MCA) Code of practice and Deprivation of Liberty Safeguards (DoLS). This helped to protect the rights of people who may not be able to make important decisions themselves.
People had access to a range of health care professionals to help maintain their health. A varied diet was provided to people which took into account dietary needs and preferences so their health was promoted and choices could be respected. Some people were not provided with adequate support to eat their meal, which meant the meal time was not a positive experience for them.
People living at the home, and their relatives said they could speak with staff if they had any worries or concerns and they would be listened to.
We found new activity workers had been employed to improve people’s choice of activity.
There were effective systems in place to monitor and improve the quality of the service provided. Regular checks and audits were undertaken to make sure full and safe procedures were adhered to. People using the service and their relatives had been asked their opinion via questionnaires. The results of these had been audited to identify any areas for improvement.
We found one breach in the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was a breach in regulation 18: Staffing.
As part of the inspection we spoke with the deputy manager, a senior care worker and six care workers about aspects of their roles and responsibilities.
We spoke with eight people living at Cotleigh and two relatives about their experiences of the support provided.
This was a follow up inspection to check improvements had been made to assessing and monitoring the quality of service provision.
On our previous inspection on 24 June 2014 we identified concerns in relation to the quality assurance processes in place to ensure internal systems were checked and monitored so people were kept safe.
The manager of Cotleigh submitted an action plan following our inspection which detailed the actions they intended to take in order to achieve compliance.
Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.
Is the service well led?
We visited the service on 15 September 2014 to check improvements had been made to the quality assurance processes in place to ensure systems were checked and monitored. We found the quality monitoring and assurance systems had been adhered to and relevant checks and audits had been undertaken and responded to. This showed any potential risks had been identified and acted upon to ensure the home was monitored and kept safe.
People living at Cotleigh told us that they had no worries or concerns but could speak to staff if they had.
We gathered evidence against the outcomes we inspected to help answer our five key questions; is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?
Below is a summary of what we found. The summary is based on speaking with people using the service, the staff supporting them and from looking at records.
If you want to see the evidence supporting our summary please read our full report.
Is the service safe?
People supported by the service, or their representatives told us they felt safe.
People told us that they felt their rights and dignity were respected.
Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.
We found that risk assessments had been undertaken to identify any potential risk and the actions required to manage the risk. This meant that people were not put at unnecessary risk but also had access to choice and remained in control of decisions about their care and lives.
The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards although no applications had needed to be submitted. Relevant staff had been trained to understand when an application should be made and how to submit one. This meant that people would be safeguarded as required.
The service was safe, clean and hygienic.
Is the service effective?
People's health and care needs were assessed with them and their representatives, and they were involved in writing their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required.
Staff were provided with training to ensure they had the skills to meet people's needs. Managers' were accessible to staff for advice and support. Staff were provided with formal individual supervision and appraisals at an appropriate frequency to ensure they were adequately supported and their performance was appraised.
Visitors confirmed that they were able to see people in private and that visiting times were flexible.
Is the service caring?
We asked people using the service and relatives for their opinions about the support provided. Feedback from people was positive, for example; 'it is very good here, the staff are very caring', 'they (staff) give me the help I need' and 'they (staff) are lovely. Just ask and you get'.
When speaking with staff it was clear that they genuinely cared for the people they supported and had a good knowledge of the person's interests, personality and support needs.
People using the service and their relatives completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed.
People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.
Is the service responsive?
People regularly engaged in a range of activities in and outside the service. The home had access to a shared adapted minibus, which helped to keep people involved with their local community.
Some people required specialised diets for health or personal reasons. We found the service provided food and drinks specifically requested by people. People told us, 'The food is good home cooking, they (staff) always ask us what we want to eat' and 'we always have drinks. I can't complain about the food at all'.
People spoken with said they knew how to make a complaint if they were unhappy. We found that appropriate procedures were in place to respond to and record any complaints received. People could be assured that systems were in place to investigate complaints and take action as necessary.
Is the service well-led?
The service worked well with other agencies and services to make sure people received their care in a joined up way. However, we found some information had not been shared with agencies that managers have a responsibility to report to. This meant that full and safe procedures had not been adhered to so that people's safety and well-being was promoted.
The service had a quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. However, we found that some audits had not been undertaken at the identified frequency. This posed a risk as full monitoring had not taken place to identify and act on any issues.
Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and the quality assurance processes in place. This helped to ensure that people received a good quality service at all times. Whilst staff were provided with a range of training, we found the procedures for the provision of refresher training had not always been adhered to so staff skills were maintained.
We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance, and the improvements they will make to ensure information is shared with appropriate agencies and that audits and refresher training is completed at the required frequency.
Three relatives spoken with said that they were happy with the care their loved ones received. Comments included, 'it is excellent here. I really cannot fault them' and 'I am very happy with the support (my relative) gets.'
During the inspection we were able to observe people's experiences of living in the home. The interactions between people living at the home and staff appeared positive. Staff spoken with knew the people living at the home well. We found that support was offered appropriately to people.
We found that before people received any care or treatment they were asked for their consent and the staff acted in accordance with their wishes.
We found that people's care and welfare needs were assessed and each person had a written plan of care that set out their identified needs and the actions required of staff to meet these. People who used the service were not protected against the risks of receiving unsafe care, which did not protect their welfare.
We found that medicines were being obtained, recorded, handled, dispensed and disposed of in a safe way.
The provider had a satisfactory recruitment and selection procedure in place to ensure that staff were appropriately employed.
The provider had an effective complaints system available.
Seven relatives spoken with told us that they had no concerns regarding their loved ones care. They said that they were always made to feel welcome and could speak to the staff about anything. They told us that staff always kept them updated regarding their loved ones health. All of the relatives spoken with praised Cotliegh and the staff very highly. Some relatives told us that they would not hesitate to recommend the home.
We spoke with Sheffield Local Authority, Contracting, Commissioning and Safeguarding and they told us that they had not identified any concerns at the home.