This inspection was completed on 4 and 10 July 2018 and was unannounced.

Cotswold House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Cotswold House accommodates 45 people in one adapted building. There were 29 people living at Cotswold House at the time of the inspection.

There was no registered manager in post at the service as the previous registered manager had left their post four months before the 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 of the Health and Social Care Act 2008 and associated Regulations about how the service is run. A new manager had started working at the service and was in the process of registering with the Care Quality Commission.

The previous inspection was completed in March 2017 and the service was rated ‘Good’ overall. At this inspection we found several concerns and the service was rated ‘Requires Improvement’ overall. During the inspection, the manager informed us about some of the measures they had implemented immediately to drive improvement. This included completing reviews of people’s mental capacity assessments, reviews of people’s care plans and arranging for further staff training.

Staff supported people to remains safe. However, risk assessments were not always reviewed and updated to ensure staff had up to date information about people’s risk management plans. People received their medicines as prescribed. Improvements were needed to ensure medicine stocks would always be recorded accurately to prevent medicine errors occurring.

Staff had received training appropriate to their role. Although staff gave choice to people, the service was not always adhering to the principles of the Mental Capacity Act 2005 (MCA). People who lacked the mental capacity to make decisions about their care and treatment were not always supported to have maximum choice and control of their lives and staff might therefore not always support them in the least restrictive way possible.

Improvements were required to ensure people’s care plans and associated documents were person centred and designed to meet their individual wishes, preferences and needs. In the absence of regular review of people’s needs we could not be assured that the care people received was appropriately tailored to their needs for example, when they received end of life care.

The new manager had identified some of the shortfalls we found prior to the inspection. They had developed an action plan to address these concerns. However, the quality assurance systems had not always been effective in identifying and addressing shortfalls in relation to seeking consent from people and risks related to the environment. In other cases, where action had been taken, this had not been sufficient to address concerns. For example, we looked at care plans which had been re-written to make them more person centred. However, we found these were either not up to date or lacked person centred information.

People, relatives and staff spoke positively about the manager. There was a positive culture in the service based on providing on care which was tailored to and met the individual needs of people. Where complaints had been raised, these had been managed appropriately.

Staff had received training around safeguarding and were confident to raise any concerns relating to potential abuse or neglect. There were sufficient numbers of staff working at Cotswold House. There was a robust recruitment process to ensure suitable staff were recruited.

People could choose what they liked to eat and drink and were supported on a regular basis to participate in m

There was one breach of legal requirements at the last inspection in August 2015. At our comprehensive inspection on 22 and 23 March 2017 the provider had followed their action plan which they told us would be completed on 11 January 2016 with regard to meeting the requirements of the regulations

Cotswold House Care Home provides care for up to 48 older people who have nursing needs. Cotswold House Care Home is split into two areas. The main house and the bungalow. The main house is arranged over three floors and the bungalow is all ground floor accommodation. There is a lift in the main house to enable people access to all areas of the home. At the time of our inspection, there were 39 people living at Cotswold House.

There was a registered manager in post at Cotswold House. They told us they had been working as manager in the home for three years. 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.’

People received exceptionally personalised care and staff found creative ways to enable people to live as full a life as possible. The arrangements for social activities were innovative and people were encouraged and supported to engage with community activities and events outside of the service. This included Dementia walks’ in the local park and a weekly Art Therapy session at the local ‘Fresh Ground Café, which was run by a person living at the home and attended by a mix of community members. People had end of life care plans which reflected their needs and preferences. Extensive work had taken place to ensure staff had excellent skills to support people and their families during these difficult times.

The service was safe. Risk assessments were implemented and reflected the current level of risk to people. There were sufficient staffing levels to ensure safe care and treatment to support people. Staff had a good awareness of safeguarding policies and procedures and felt confident to raise any issues of concerns with the management team. The registered manager had carried out the relevant checks to ensure they employed suitable people at Cotswold House.

People were receiving effective care and support. Staff received appropriate training which was relevant to their role. Staff received regular individual meetings called supervisions and appraisals. Where required, the service was adhering to the principles of the Mental Capacity Act 2005 (MCA) or Deprivation of Liberty Safeguards (DoLS). The environment had been adapted to meet the needs of people living at the home. People were supported to personalise their living spaces.

The service was caring. People and their relatives spoke positively about the staff at the home. Staff demonstrated a good understanding of respect and dignity and were observed providing care which maintained peoples dignity. People had end of life care plans which reflected their needs and preferences.

There was a complaints procedure in place and where complaints had been made, there was evidence these had been dealt with appropriately.

The service was well-led. There was an experienced registered manager working at the service. Staff, people and their relatives spoke positively about the registered manager. Quality assurance checks and audits were occurring regularly and where issues had been identified action had been taken to address them. The registered manager and staff were aware of the vision and values of the service and worked hard to provide a service which was person centred for each individual.

The purpose of the inspection was to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people using the service, their relatives, the staff supporting them and looking at records.

If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

People told us “It’s lovely here, I feel safe and staff respond promptly to my call bell”. Another person told us that sometimes they had to wait for staff to assist them and understood that staff were supporting other people. They told us “I am not the only person here so I quite understand”. Call bells were in easy reach of people who used the service and staff were observed responding to call bells promptly. This was monitored by the manager.

Care records included clear information about how people were to be supported and the equipment needed to safely assist people with moving and handling.

We observed staff in the communal areas of the home supporting people in a timely manner and assisting people using appropriate moving and handling equipment.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

People had been cared for in a safe, clean and hygienic. Regular audits were completed on the environment to ensure they were safe and any risks were minimised.

Staff received suitable training to enable them to support people safely and understand different people’s needs.

Is the service effective?

People’s health and care needs were assessed with them, and they were involved in writing their plans of care.

We saw that people received the care set out in their care plan and people received the support that they needed.

Is the service caring?

People using the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed.

We saw that staff spoke to people in an appropriate manner and responded appropriately to their requests for assistance.

People’s preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes.

Is the service responsive?

People knew how to make a complaint if they were unhappy. We looked at how these complaints had been dealt with, and found that the responses had been open, thorough, and timely. People could be assured that complaints were investigated and action was taken when necessary.

Is the service well-led?

There was a manager in the service that was registered with the Care Quality Commission. People knew who the manager was and felt they could raise concerns with either the manager or the staff and this would be responded to appropriately.

The service worked well with other agencies and services to make sure people received their care in a joined up way.

Staff told us they were clear about their roles and responsibilities. Staff received regular training to enable them to fulfil their roles and this was kept under review.

The service had a quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

We visited this home to investigate concerns brought to our attention by a relative of a person living in the home. They told us that their family member did not receive prompt attention in support of their continence needs and that they witnessed other people become distressed by lack of prompt support. They said that people in the home were bored and did not have enough stimulating activities to occupy them. They were also concerned about the physical environment of the home which they said was unclean, and poorly maintained. They told us they had frequently complained to the home but things did not improve. They told us that the home's manager was rarely in evidence in the home, although we found that the manager regularly worked in excess of her contracted hours.

When we visited we spoke with people who lived at Cotswold House, with staff and with the home's manager and director. Some people told us they were well cared for but most expressed concerns about the time that they had to wait when they asked for assistance. There was also dissatisfaction about the lack of activities in the home and about the standard of meals.

We found that the physical environment of the home was uninviting, untidy and in some areas poorly maintained. There was a lingering stale smell and a smell of urine in some parts of the home. The home was not cleaned to an acceptable standard.

When we visited this home in September 2012 we had serious concerns and took enforcement action, requiring the provider to take immediate action to improve standards. The provider agreed to limit occupancy of the home to 40 people until such time as we were satisfied that improvements had been made. This was a follow up inspection to check that improvements had been made.

We previously had concerns that people's care needs were not consistently reviewed, risks were not properly managed and people did not always receive the care they needed. We had concerns about the management of medicines, staffing levels and the support provided to staff. There were inadequate systems to monitor the quality of service.

At our return visit we noted some improvements however we remained concerned that care plans did not always reflect people's current needs. Poor documentation meant that we could not be assured that care was regularly reviewed, evaluated and consistently provided. We saw improvements in the management of medicines but there remained problems with supply. Staffing ratios had improved, but there was still high usage of relief staff. The home had not appointed a manager, but we acknowledged efforts to rectify this and the appointment of a deputy manager. Staff were better supported with training and supervision but appraisal was still outstanding. Systems to monitor quality had improved but were still not sufficiently robust to provide assurance of quality and safety.

This was a planned inspection which was arranged so that we could check that previous areas of non compliance had been addressed.

We previously visited this home in March 2012. At that time we had concerns in a number of areas. Processes under the Mental Capacity Act 2005 for gaining consent or making best interest decisions for people who lacked mental capacity were not sufficiently understood or followed by the staff. Some people were not receiving the care and support they needed. Staff had insufficient knowledge or training about safeguarding procedures and their responsibilities to report incidents to the relevant authorities. We had concerns about the handling of medicines. Staff also had insufficient training in caring for people with dementia, managing challenging behaviour and restraint. We raised concerns that there were insufficient staff on duty at night. We were also concerned that staff received inadequate supervision and training. Systems for monitoring safety and quality were inadequate.

The service was not consistently reporting important events that affect people’s health, welfare and safety to CQC. The service did not have a registered manager in post and arrangements to cover this absence were inadequate.

The provider submitted an action plan which outlined the actions they intended to take in order to achieve compliance. We made a return visit on 19 and 21 September 2012 to check their progress with this.

We had also received concerning information from a family member of somebody who lived at Cotswold House. They told us their relative was not provided with adequate support with continence. They told us they frequently found their relative wet or soiled and this caused them distress. They told us that they also witnessed other people wait too long for support. They also told us that sometimes there were only two care staff on duty at night, responsible for over forty residents, although we found no evidence to support this.

During our recent visits we spoke to eight people who lived at Cotswold House. They spoke very positively about the staff, describing them as “kind” and “caring”. They were less positive about temporary staff who were frequently employed to cover staff absences, particularly at night. One person told us that they sometimes did not receive assistance to go to bed until after midnight. They told us they were left in the downstairs lounge and they felt anxious and vulnerable because they did not have access to a call bell. They told us that when they complained to agency staff about this they were told “We’re busy”.

During our visits we observed staff interacting with people in a friendly, polite manner. The staff were very busy and we heard call balls ringing frequently. The home did not employ a receptionist and the manager was absent so staff also had to frequently answer the telephone and the front door. We observed that staff administering medicines were repeatedly interrupted. On two occasions we were asked by people seated in the lounge if we could locate a member of staff so that they could be assisted to the toilet.

We spoke to six staff and a director of the organisation. Staff told us they felt well supported but records showed that staff training and supervision was not up to date. Some staff told us that they thought staffing levels at night were inadequate. The provider had recently reviewed staff routines at night and had concluded that the staffing levels were appropriate. However they were unable to demonstrate that staffing levels were assessed and reviewed based on an up to date and ongoing assessment of people’s needs.

Some people living at Cotswold House had dementia and did not have the mental capacity to make decisions about or consent to their care and treatment. We found that staff had insufficient training and understanding of the Mental Capacity Act and the provider had failed to comply with legal requirements in respect of consent.

We found that some improvements had been made in respect of managing people’s medicines. However we found that the ordering system was inefficient and led to delays in people receiving their medicines.

We saw gaps in people’s medicine administration records and could not therefore be assured that people were consistently receiving their medicines. We were also concerned about a lack of clear information about the administration of medicines which were prescribed as “as required”.

As we went around the home we identified a number of concerns with regard to the environment. Some parts of the home were in a poor decorative state and there were a number of repairs which needed action. We also found concerns with infection control practices, in particular inadequate hand washing and waste disposal facilities.

People told us they were happy with the service looking after their medicines and how they were being administered.

Some people we spoke to were able to tell us what they thought of the service, many were not able to do this.

Comments such as “nice place to live” and “it’s alright here” told us that these people like living at the service and have settled.

Comments about the food gave us reassurances that, although you could not please everyone all the time, that generally people liked the food.

There were mixed views on the activities provided. Several enjoyed a weekly visit to the local church where they chatted and had a cup of tea. On asking what there was if you did not go to this, one person said “nothing going on at the moment, its been like this since the activity co-ordinator left” but another said they enjoy the music sessions.

Everyone we spoke to said the staff were kind and helpful. This also seemed to be echoed in written compliments and in a the services survey carried out in March 2011.

The service had not received a high number of complaints.

People told us they are happy in the home and they feel well looked after. One person said, “the staff wait on me and I never have to wait when I ring my bell”

Another person said, “the home is well run and the staff are very good”. A relative told us that the care is good and their relative is always tidy and looks well cared for. They also said that the staff include them in the care of their relative and keep them up to date with any changes. This relative said, they were “very impressed with this home”.

People said that they are able to make choices about their daily lives for example, where they want to have their meals and if they wish to spend their days in their own room or in the communal areas.

People told us they liked the food and they are offered choices. One person said “the food is good here”. Another person said the food is not to their liking but they are happy to eat it.

This inspection was completed over two days 13 and 18 August 2015. Cotswold House Care Home provides care for up to 48 older people who have nursing needs. At the time of our inspection there were 42 people living in home.

Cotswold House Care Home is split into two areas. The main house and the bungalow. The main house is arranged over three floors and the bungalow is all ground floor accommodation. There is a lift in the main house to enable people access to all areas of the home.  There were 44 single and two double (shared) bedrooms, with 38 bedrooms having an ensuite facility of a toilet and wash hand basin.

There was a registered manager working at the service. 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.

Whilst the home was clean and free from odour. Some improvements were required to ensure people were safe in respect of reducing the risks of cross infection in respect of equipment cleaning and ensuring bathrooms were fit and ready for use for the next person.

Staffing in the home had recently been increased. We found there was a difference in the care delivery on the first day of the inspection. This was because the service was short of staff. This meant the care was not as effective and responsive as on the second day. There was a high usage of agency staff which the provider and the registered manager were actively trying to reduce with the recruitment of new staff. Assurances were given that regular and familiar agency staff were used who knew the people and the home.

Care plans were in place that described how the person would like to be supported and these were kept under review. Some improvements were made during the inspection to ensure risk assessments detailed individual risks and what action staff should take to keep people safe. This was because these were generic and did not focus on the person.

People’s medicines were managed safely. People were protected from abuse because staff had received training on safeguarding adults and they knew what to do if an allegation of abuse was raised.

People had access to healthcare professionals when they became unwell or required specialist help. They were encouraged to be independent and to participate in activities both in the home and the local community.

People were treated in a dignified, caring manner which demonstrated that their rights were protected. People confirmed their involvement in decisions about their care. Where people lacked the capacity to make choices and decisions, staff ensured people’s rights were protected. This was done through involving relatives or other professionals in the decision making process.

Staff were knowledgeable about the people they supported and spoke about them in a caring way. Staff had received suitable training enabling them to deliver safe and effective care. Newly appointed staff underwent a thorough recruitment process before they commenced work with people.

People’s views were sought through care reviews, meetings and surveys and acted upon. Systems were in place to ensure complaints were responded to. People who used the service, their relatives and staff were positive about the management of the home, which was open and approachable.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.<Summary here>