The Cottage Residential Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, staffing, safeguarding and consent.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was not a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Feedback from partners was not always positive, a recent visit to the service by the local authority resulted in them putting additional staff into the service to support the people they commissioned and to keep people safe.

The managers overseeing the service did not have the relevant knowledge to understand legislation in relation to managing risk to either people or the environment.

The managers overseeing the service did not always follow safe systems of care or identify safety issues.

Some guidance in place from healthcare partners was not understood or followed to keep people safe. We observed staff assisting 1 person to drink which did not follow the guidance provided by the speech and language team. The guidance stated their fluid should be thickened to reduce the risk of coughing, choking, or the fluid going down the wrong way, however, as stated during our observation this guidance was not followed or understood by staff.

When we reported this back to the manager their response also confirmed they lacked understanding of the potential risk of not following this guidance from a healthcare partner.
 

The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Safeguarding processes had not been followed. We identified multiple incidents that had not been reported to the local authority or CQC. For example, we identified an entry in a person’s care plan recording they had fractured their hip in September 2022. This had not been reported to either safeguarding authorities or CQC.

Another incident resulted in a person falling and hitting their head sustaining a cut to their head. There was no recorded medical advice or evidence that treatment had been obtained following a head injury. This had not been reported to either safeguarding authorities or CQC.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Whilst deprivation of liberty authorisations or applications were in place, oversight of these were not robust as we identified instances of authorisations expiring before staff were aware. This meant another application needed to be sent. Mental capacity assessments were either not in place or not reviewed. One person who had an authorisation in place did not have any mental capacity assessments or best interest information within their care records. Another person’s mental capacity assessments were dated 2017 with reviews of these ending in either 2022 or 2023.
 

The service did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people using the service were not being appropriately identified, assessed, or managed, placing people at risk of avoidable harm. Risk assessments were either incomplete or inconsistent and staff were not following the guidance. One person required a special diet and we observed staff not adhering to this guidance placing the person at risk of choking. When we asked staff about this, they were not aware of the guidance. We then pointed this out to the manager who again gave us a response which identified a clear lack of understanding to the risks associated with not following the specific guidance related to this person’s diet.

Two people had clear guidance related to their bowel management and again this guidance had not been followed. Risk assessments were often undated and whilst staff were recording reviews monthly these frequently recorded “no change” which did not assure us the information was up to date and accurate.

We found personal emergency evacuation plan (PEEPs) records were in place though these records were undated so we could not be assured they contained up-to-date or accurate information relevant to each person’s current needs and status of their mobility.
 

The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

We reviewed the fire risk assessment dated 3 June 2025. The priority actions at the back of the fire risk assessment were dated from 2019. We were not assured a competent person had carried out the risk assessment. We had been made aware the fire service had issued actions the home needed to undertake but the manager was unable to provide us with this report or the actions they had completed.

Fire drills were carried out and whilst it stated the number of staff and service users that attended, there were no staff names recorded so the manager would not be aware of staff who may not have had the opportunity to attend. We found no evidence staff working at night had attended a fire drill.

During the inspection, we observed poor storage practices that could contribute to increased fire risk. Specifically, bedding was found stored on top of a wheelchair outside the laundry room, and items of clothing were placed on top of washing machines. The improper storage of bedding, particularly when placed near heat sources or obstructing fire exits, significantly increased the risk of fire spread and may impede safe evacuation in the event of an emergency.

We identified shortfalls in the oversight of Legionnaires management. The last Legionnaires’ water testing check had expired and the due date for the retest was overdue. While regular water testing was recorded, no records were available to confirm that unused outlets were being flushed or that descaling had taken place. This had potential to significantly increase the risk of Legionnaires’ disease, a potentially fatal condition, due to the potential for Legionella bacteria to thrive in stagnant water systems. The arrangements to identify unsafe health and safety matters were not safe as chemicals were not stored safely. This placed people living at the service at risk of harm and injury. For example, cleaning products were stored under the sink in the kitchen; this cupboard was found unlocked. Other cleaning products were found in another unlocked cupboard in the kitchen and in the laundry room. One person had a risk assessment in place identifying a risk of them being left unsupervised with access to chemicals. However, during the assessment, we observed this person unsupervised in the environment on several occasions.

The overall maintenance and appearance of the service was extremely poor including people’s bedrooms. For example, in 1 bedroom there was a crack and a damp patch on the ceiling. In another bedroom carpet was missing from the steps leading to this bedroom.

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

There was a lack of robust oversight in relation to staff training and competency. The service did not have a training plan or matrix in place, which impacted on the manager’s ability to monitor staff compliance with mandatory training. The manager informed us that training records were being updated; however, staff had not received recent practical manual handling training, and no staff had completed training in relation to the International Dysphagia Diet Standardisation Initiative (IDDSI). This framework provides a standardised system of terminology and definitions for describing food textures and drink consistencies for people with dysphagia, or difficulty swallowing. This lack of training led to the local authority placing agency staff to support a person with a specialist diet, highlighting the impact of these gaps on safe care delivery.

We also reviewed staff files and found yearly competency observations that were almost identical across two different staff members, raising concerns about the validity of the assessments. In 1 file, the most recent appraisal was dated 2020, indicating a lack of ongoing performance review and development.

The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The overall cleanliness and hygiene standards at the service were poor, posing risks to people living at the service. A large oven, housed in the main kitchen chimney breast and confirmed to be in regular use, was found to be extremely dirty. Oven trays stored inside were rusted and ingrained with debris, and the warming drawer although not in use contained visible mould and mildew. Oven gloves were heavily soiled and stored over the oven handle.

Multiple food items were found beyond their expiry dates, including uncooked chicken breasts and a beef lasagne stored in a fridge/freezer located in the laundry room. The chicken was stuck to the bottom of the fridge with ice particles, and the freezer drawers were iced over and inaccessible. Using food past its "use-by" date significantly increases the risk of foodborne illness, particularly for older adults and those with compromised immune systems.

Toilet brushes in some rooms were unclean, and the main ground floor bathroom had cracked floor tiles. When asked for cleaning schedules, staff provided a laminated instruction sheet indicating the oven should have been cleaned the night before the assessment which meant the instructions were not being followed.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Medicines processes were not safe. We identified 1 person who had a potential under dose of 2 tablets. This had not been identified by the service. This placed the person at risk of not receiving the therapeutic dose of their medicines. We informed the manager immediately of this concern.

The management of medicines requiring additional controls around storage and administration was not robust. We found the stock balance for a person no longer at the service was still showing a balance in stock. We found no stock for this medicine.

Other medicines we were unable to reconcile as carry forward amounts had not been recorded on medicine administration records (MAR). We identified on our review that medicines on the morning of our visit had been administered with medicine records unsigned. One medicine we were able to reconcile indicated an excess of stock which meant we were not assured this had been administered as the prescriber’s instructions.

We identified that people were being were being administered medicines beyond the recommended expiry date following opening. This placed people at risk of harm. One person was prescribed cream in May 2025 and this was found unopened and unused.