Archived: Cottesmore House

Updated 29 July 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 29 March 2017 and was unannounced. This inspection was carried out by one inspector. We inspected the service against one of the five questions we ask about services: is the service well-led. This is because we had issued the provider with a warning notice where the last inspection had identified a repeated breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to the governance and leadership of the service.

During the inspection, we reviewed the medicines management system, including the medicines Administration Record (MAR) charts for two people and the last two medicines audits, health and safety checks, mental capacity assessments for five people, team meeting minutes and a record of the monthly inspection carried out by the care manager.

We spoke with the director, the care manager and a senior care worker.

Updated 29 July 2017

This unannounced inspection took place on 29 March 2017. The last inspection of the service took place on 17 and 18 January 2017, when we rated the service as Requires Improvements overall and identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which related to Safe Care and Treatment and Safeguarding service users from abuse and improper treatment. We also found a repeated breach of Regulation 17 Good Governance in relation to medicines management, safety and capacity and consent. As a result, we issued the provider with a warning notice telling them they must make the required improvements by 03 March 2017.

At the inspection of 29 March 2017, we checked if the provider had put in place adequate systems to monitor, assess and make improvements. We found the provider had taken action and improved the way they managed medicines, assessed risks to people’s health and safety and worked within the principles of the Mental Capacity Act (2005). This meant that the provider had met the requirements of the warning notice.

This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for ‘Cottesmore House’ on our website at www.cqc.org.uk.

Cottesmore House is an extra care housing service that provides personal care for up to 47 people. Each person was living in their own flat and had their own tenancy with Paradigm Housing Association who also owned the building. There were eight flats on the fifth floor which were exclusively for people who were living with a learning disability.

There was a registered manager in post at the time of our 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 in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There were effective systems in place for the management of prescribed medicines.

The provider had put in place robust health and safety checks and action was taken where issues were identified.

Where people lacked the capacity to manage their own medicines, the provider had carried out a mental capacity assessment and had acted in the person’s best interest.

While improvements has been made we have not revised the rating for this key question; to improve the rating to ‘Good’ would require a longer term track record of consistent good practice.

We will review our rating at the next comprehensive inspection.