This inspection took place on 7 and 8 March 2018. It was an unannounced visit to the service.

We previously inspected the service on 4 and 12 December 2015. The service was meeting the requirements of the regulations at that time and was rated ‘Good’ overall.

Cotswold Cottage 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. Eight people were living at the service at the time of our inspection. People had complex learning and physical disabilities.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

The service had a registered manager in post. 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.

We received positive feedback about the service. A healthcare professional told us “From what I have observed and heard from the staff, they manage and cope well with complex patients such as tube fed patients, alongside having the appropriate tools to manage such patients…If staff have any queries then they do not hesitate to contact myself for advice or another dietetic assessment.”

People were kept safe at the service. Robust recruitment procedures were used to make sure staff had the right skills to support people. Medicines were managed safely. Improvements had been made to standards of cleanliness at the home.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Staff received support to help them develop as workers and to meet the needs of the people they cared for. This included regular meetings with their managers and good training opportunities.

People’s nutritional and healthcare needs were effectively met. Staff followed any guidance from community professionals to keep people healthy and well.

Staff were kind and caring towards people. They promoted people’s independence and treated them with dignity and respect.

People received person-centred care. Their needs were recorded in written care plans; these were kept up to date. People were supported to take part in social activities. There were procedures for making complaints and compliments about people’s care.

The service was managed well. The provider carried out checks and audits of people’s care to ensure it met their needs. Recent audits showed the service was performing well.

This inspection took place on 04 and 11 December 2015. The first day of the inspection was unannounced; the second day was announced.

We previously inspected the service on 24 April 2014. The service was not meeting the requirements of the regulations at that time in one area of practice: assessing and monitoring quality of care. The provider wrote to us and told us what action they would take to make improvements at the home. We carried out a desktop review in August 2014, when we found the home was meeting the regulations.

Cotswold Cottage provides accommodation for up to eight adults with learning disabilities. Seven people were living at the home at the time of our inspection.

The service had a registered manager in post. 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.

We received positive feedback about the service. Comments from people included “The new manager is very hands on and proactive in looking after the welfare of the residents” and “The staff I have met with have always shown a caring and respectful stance towards the service users within this service.” A relative told us their family member “Has been happy with the care that they have received and formed positive relationships with staff and other service users. When there have been changes in the home and in their life, they have been handled sensitively and professionally with health and safety as a priority.” Another relative said “The manager continues to manage Cotswold very well in spite of the problems caused by a lack of good staff. Some of the newer staff have the qualities that we like to see. They are willing and able and are determined to give the clients those extras that should be a right not an exception.”

We found people were protected from the risk of harm. Staff had undertaken training on recognising and reporting signs of abuse. Any concerns were referred to the appropriate agencies, such as the local authority and the Care Quality Commission.

Robust processes were used when recruiting staff, to ensure they had the right skills and attributes to work with vulnerable adults. Staff undertook training to keep their skills and knowledge up to date.

Some of the feedback we received was about staff vacancies at the home and the implications this may have on the consistency of people’s care. We found the home had advertised vacant posts and was interviewing prospective staff members whilst this inspection was in progress. Temporary care staff were being provided by recruitment agencies. We saw a consistent, small group of temporary staff were working at the home. Those we met worked well with the people they supported to ensure needs were met.

People’s health and welfare needs were being met. Staff supported people to access healthcare agencies as necessary. Any recommendations made by external professionals were put into practice by staff. People received their medicines safely.

The building complied with gas and electrical safety standards. Areas to improve the building had been identified by the registered manager and provider. Agreement had been given for work to go ahead to improve the environment.

The service was managed well by an experienced registered manager. Records were maintained to a good standard and staff had access to policies and procedures to guide their practice. The provider monitored the service to make sure it met people's needs safely and effectively.

We have made a recommendation about cleanliness at the service.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask:

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well-led?

This is a summary of what we found -

Is the service safe?

Staff followed safe medication practices at the home. We saw all medicines were locked away, to prevent unauthorised access. We found medicines were safely administered. Staff who handled medication had received training on safe management and administration of medication and their competency had been assessed. This ensured they had the skills and knowledge to manage people’s medicines safely.

There were policies and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. No applications had needed to be submitted to deprive anyone of their liberty. Relevant staff had been trained to understand when an application should be made, and in how to submit one. This ensured there were proper safeguards in place.

Is the service effective?

Equipment such as hoists and adapted baths were provided at the service to meet people's needs. Equipment was serviced to make sure it was safe to use. Staff had been trained in moving and handling techniques to make sure they carried out manoeuvres safely.

Is the service caring?

People’s privacy and dignity were respected. We observed personal care was carried out behind closed doors. We noted people who used the service had been supported to look presentable in clean, co-ordinating clothes. Clothes protectors were used at meal times to prevent spillages soiling people’s clothing. We saw staff wiped people’s mouths after the evening meal, to remove any traces of food.

People were supported to be independent. Staff provided people with aids and adaptations to help them manage their evening meal. For example, plate guards and adapted beakers. This meant some people could manage to eat their meal without support from staff. Staff supported people to access the community. For example, going into town to buy clothes, having pub lunches and attending the surgery for GP appointments.

Is the service responsive?

Care plans were in place for each person. These provided a comprehensive account of the support people required. We saw risks to people’s safety and welfare were identified and measures put in place to reduce the likelihood of injury or harm. People had access to healthcare professionals, such as GPs and the consultant in learning disabilities, to help keep them healthy and well.

Is the service well-led?

The provider had a system of carrying out annual quality assurance audits of its services. The last annual audit took place in April 2013 and showed the home was providing good standards of care to people. The next annual audit was due to take place shortly after our inspection, to re-assess standards of care.

There was an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others. Risk assessments were in place, such as personal emergency evacuation plans, moving and handling assessments and nutritional screening. These had been kept under regular review to ensure information was correct and reflected people’s needs.

The provider had a system to regularly assess and monitor the quality of service that people received. However, we saw this had not been fully implemented at the home. We found monitoring of the service had not been undertaken monthly by senior management, as expected by the provider. This meant the quality of care had not been regularly assessed and monitored in line with the provider’s guidelines, to ensure it was meeting people’s needs.

When we visited the service on 4 January 2013, we had concerns about how staffing was being managed. This was because we found occasions when there were insufficient staff on duty to safely meet people's needs. We set a compliance action for the provider to improve practice.

We returned to the service on 15 April 2013 to check whether improvements had been made. We found the manager was using agency and relief staff to cover any gaps on the staff rotas. For example, when staff were sick or to cover vacant posts. This meant there were now at least three staff on duty during the day at peak times. The senior member of staff on duty told us the agency was supplying workers who could attend the home regularly. This helped to ensure people received continuity of care.

We were satisfied the home had made improvements which ensured there were enough skilled and experienced staff to meet people’s needs.

We found people using the service were unable to give consent to their care at the home, or treatment from healthcare professionals. This was due to the complexity of their disabilities. Records showed some evidence of people's relatives being involved in decision making. Care plans advocated staff offering people choices wherever possible, for example, in what clothes they wore.

Care plans were in place to document people's individual needs. Risk assessments had been written to identify and reduce the likelihood of injury or harm. We found people had access to healthcare professionals and specialist support to help keep them healthy and well.

Infection control was managed well. There were procedures in place to provide guidance for staff. Training was undertaken to equip them with the necessary skills and knowledge.

We found there were not always enough staff to support people. Procedures for covering the home with external staff were not being followed. For example, if relief staff could not cover gaps on the rota. This left the home with insufficient staff to safely meet the needs of people using the service. Staff we met were knowledgeable about people's needs. We saw staff had undertaken various courses to provide them with the skills to meet people's needs.

There was a statement of purpose in place. This provided all required information about the service and would be useful to people looking for a care home placement.

One person told us they had enjoyed a firework display recently. They said they were looking forward to the Christmas party at the service, especially cakes and biscuits. People indicated that they have contact with their families. Some people were able to tell us they liked going to day services. One person showed us that she had been given her choice of sandwich filling in her packed lunch. We saw people who could not communicate verbally smiling and looking relaxed.

Staff that we spoke with said they felt supported in their roles and there was a good sense of teamwork. They said regular staff meetings took place and that training was 'excellent'.