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Archived: Cottesmore House Requires improvement

The provider of this service changed - see new profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 29 July 2017

This unannounced inspection took place on 29 March 2017. The last inspection of the service took place on 17 and 18 January 2017, when we rated the service as Requires Improvements overall and identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which related to Safe Care and Treatment and Safeguarding service users from abuse and improper treatment. We also found a repeated breach of Regulation 17 Good Governance in relation to medicines management, safety and capacity and consent. As a result, we issued the provider with a warning notice telling them they must make the required improvements by 03 March 2017.

At the inspection of 29 March 2017, we checked if the provider had put in place adequate systems to monitor, assess and make improvements. We found the provider had taken action and improved the way they managed medicines, assessed risks to people’s health and safety and worked within the principles of the Mental Capacity Act (2005). This meant that the provider had met the requirements of the warning notice.

This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for ‘Cottesmore House’ on our website at www.cqc.org.uk.

Cottesmore House is an extra care housing service that provides personal care for up to 47 people. Each person was living in their own flat and had their own tenancy with Paradigm Housing Association who also owned the building. There were eight flats on the fifth floor which were exclusively for people who were living with a learning disability.

There was a registered manager in post at the time of our inspection. 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 2008 and associated Regulations about how the service is run.

There were effective systems in place for the management of prescribed medicines.

The provider had put in place robust health and safety checks and action was taken where issues were identified.

Where people lacked the capacity to manage their own medicines, the provider had carried out a mental capacity assessment and had acted in the person’s best interest.

While improvements has been made we have not revised the rating for this key question; to improve the rating to ‘Good’ would require a longer term track record of consistent good practice.

We will review our rating at the next comprehensive inspection.

Inspection areas

Safe

Requires improvement

Updated 23 February 2017

The service was not always safe.

A disabled toilet was dirty and the toilet seat damaged which meant that there was a risk of injury and cross infection.

There were systems in place for the management of prescribed medicines, however these were not always effective.

The risks to people's safety and wellbeing were assessed and there were plans in place for all the risks identified.

There were procedures for safeguarding people and staff were aware of these.

Recruitment checks were undertaken to obtain information about new staff before they supported people unsupervised.

Effective

Requires improvement

Updated 23 February 2017

The service was not always effective.

The provider was aware of their responsibilities in line with the requirements of the Mental Capacity Act (MCA) 2005. However, where people lacked the capacity to manage their own medicines, there were no evidence that the provider had carried out a mental capacity assessment or that a best interest decision was in place.

Staff received training and were suitably supervised and appraised.

People's health and nutritional needs had been assessed, recorded and were being monitored. Staff liaised with other healthcare professionals to ensure people’s needs were met.

Caring

Good

Updated 23 February 2017

The service was caring.

Feedback from people and relatives was mostly positive about both the staff and the provider.

People and relatives said the staff were kind, caring and respectful. Most people who used the service were receiving care from regular staff and had developed a trusting relationship.

People and their relatives were involved in decisions about their care and support.

Responsive

Good

Updated 23 February 2017

The service was responsive.

People's individual needs had been assessed and recorded in their care plans prior to receiving a service, and were regularly reviewed.

There was a complaints policy in place. People knew how to make a complaint, and felt confident that their concerns would be addressed appropriately.

The service conducted satisfaction surveys with people and their relatives. These provided vital information about the quality of the service provided.

Well-led

Requires improvement

Updated 29 July 2017

We found the provider had taken action to improve the safety of people using the service.

Health and safety checks were undertaken regularly and any identified concerns were addressed without delay.

Systems were in place and being followed to manage medicines safely.

Where people lacked the capacity to manage their own medicines, the provider had carried out a mental capacity assessment and had acted in the person’s best interest.

This meant that the provider had met the legal requirements relating to good governance.

While improvements had been made we have not revised the rating for this key question; to improve the rating to ‘Good’ would require a longer term track record of consistent good practice.