Cotteridge House

Updated 18 January 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection was carried out by 2 inspectors and 1 Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Cotteridge House is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with 3 people who used the service and 8 relatives about their experience of the care provided. We spoke with 7 members of staff including the registered manager, seniors and care workers.

We reviewed a range of records. This included 8 people's care records, financial management records and multiple medication records. We looked at 2 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found, including information about the provider's staff training programme and financial management policies.

Updated 18 January 2023

About the service

Cotteridge House is a residential care home providing personal care and accommodation to up 10 people. The service provides support to older people and people with dementia. At the time of our inspection there were 8 people using the service.

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

Some people, whose personal budgets were managed by the home did not have a written agreement in place giving the provider authorisation to manage their personal budgets. The entrance to a fire door on the ground floor was blocked due to items being placed in front of the door, such as a wheelchair and cleaning equipment.

Some staff members had a temporary Disclosure and Barring Service (DBS) certificate and did not have the required risk assessment in place or evidence they were being supervised when administering care tasks.

We were not assured that the provider was supporting people living at the service to minimise the spread of infection.

Some people had mental capacity assessments records however the mental capacity assessments were not signed, no name details of the person undertaking the assessment and no date. In addition, the mental capacity assessments were not decision specific. The lack of information recorded did not assure us people were being supported to make their own decisions. Some people’s Deprivation of Liberty Safeguards (DoLS) authorisation renewals were not sent in a timely manner.

The provider had safeguarding systems and processes in place to keep people safe. Staff knew about the risks to people and followed the assessments to ensure they met people's needs.

People felt safe and were supported by staff who knew how to protect them from avoidable harm.

Audits undertaken by the provider were not effective at monitoring the quality of the service, some risk assessments lacked detail to clearly identify what mitigation was in place. In addition, some care plans did not contain enough detail.

Staff spoke positively about working for the provider. They felt well supported and that they could talk to the management team at any time, feeling confident any concerns would be acted on promptly. They felt valued and happy in their role.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for the service under the previous provider was requires improvement, (published on 11 July 2019) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about care delivery. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of Safe, Effective and Well Led.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective and Well Led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment, the need for consent and governance.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will meet with the provider following this report being published to discuss how changes will be implemented. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.