You are here

Cotman House Requires improvement

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 11 January 2020

About the service

Cotman House is a residential care home providing personal care to up to 62 older people. At the time of our inspection there were 49 people using the service, some were living with dementia.

People’s experience of using this service and what we found

Improvements were needed in how the service ensured people’s care plans were reviewed and reflected people’s current needs and how they were met. Records reviewed did not include people’s end of life decisions, the registered manager was working on improving this. The risk assessments and associated care plans and documents were contradictory and did not demonstrate the risks to people in their daily living were robustly assessed and mitigated to reduce the risks of avoidable harm. We have made requirements to improve in these areas.

There had been several changes in the management team since our last inspection. A new registered manager was in place and staff and people told us they could see improvements were being made. The registered manager was aware of the improvements needed and was working to implement them. However, these were not yet implemented and improvements identified by the provider in May 2019 had not been addressed in a timely way.

Improvements had been made to reduce the risks of people falling from balconies in some bedrooms. The environment was safe and regular checks on equipment were undertaken. Improvements had been made in how the staff recorded when people had received support with their prescribed creams and lotions. Medicines management systems were safe. We had received concerns prior to our inspection relating to staffing levels, however at the time of our inspection the registered manager was taking action to improve in this area, including the recruitment of new staff. Recruitment processes were safe. Systems were in place which were designed to reduce the risks of abuse. Infection control processes were in place which reduced the risks of cross infection.

Staff were trained and supported to meet people’s needs. 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 support this practice. People’s needs relating to their diet and hydration were being met. People had access to health care professionals where required and the service worked with other professionals involved in their care. The environment was well maintained, and the registered manager was in the process of making improvements to assist people to navigate independently around the service.

People told us the staff were caring and respectful, which was confirmed in our observations. People’s views were valued and acted on relating to how they wanted to be cared for. People’s rights to privacy, dignity and independence were promoted and respected.

People had the opportunity to participate in activities which interested them. There was a complaints procedure in place and complaints were investigated and addressed.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was good (published 30 June 2017).

Why we inspected

This was a planned inspection based on the previous rating.


We have identified breaches in relation to the assessment and mitigation of risks and how people’s care was planned for and met at this inspection. For requirement actions of enforcement which we are able to publish at the time of the report being published:

Please see the action we have told the provider to take at the end of this report.

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.

Inspection areas


Requires improvement

Updated 11 January 2020

The service was not always safe.

Details are in our safe findings below.



Updated 11 January 2020

The service was effective.

Details are in our effective findings below.



Updated 11 January 2020

The service was caring.

Details are in our caring findings below.


Requires improvement

Updated 11 January 2020

The service was not always responsive.

Details are in our responsive findings below.


Requires improvement

Updated 11 January 2020

The service was not always well-led.

Details are in our well-Led findings below.