Cottingley Hall Care Home

Updated 30 December 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.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The first day of inspection was conducted by 3 inspectors and an 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. The second inspection day was completed by 1 inspector.

Service and service type

Cottingley Hall Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Cottingley Hall Care Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post responsible for overseeing the regulated activities in the service. However, appropriate management arrangements were in place.

Notice of inspection

Both days of inspection were unannounced. Inspection activity started on 24 October 2023 and ended on 3 November 2023. We visited the location’s service on 24 and 26 October 2023.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. 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 (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spent time in the communal areas observing care and support provided by staff. We spoke with 14 people who used the service and 2 relatives about their experience of the care provided. We spoke with 10 members of staff including the manager, regional director, maintenance, nurse, and team leader.

We reviewed a range of records. This included 5 people’s care records and multiple medication records. We reviewed 3 staff recruitment files and a variety of records relating to the management of the service.

Updated 30 December 2023

About the service

Cottingley Hall Care Home is a residential care home, providing personal and nursing care to a maximum of 40 people, accommodated in 1 adapted building. At the time of the inspection there were 35 people using the service.

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

Shortfalls were identified which impacted on the safety and quality of care people received. There had been some changes to the management team which led to a lack of effective leadership at provider level. As a result governance arrangements had failed to identify all of the shortfalls we found on inspection. Feedback from people and relatives was overwhelmingly positive about the care people received. Staff were also positive and complimentary of the new manager who had recently transferred and was overseeing the service.

Systems were not always robust enough to demonstrate safety was effectively managed. Staff were inconsistent with the recording of required repositioning and food and fluid monitoring. Medicines were not always managed safely. Some of these shortfalls had not been identified through the providers own governance arrangements. Prompt action was taken once we brought this to the attention of the management team. The provider had safe recruitment process and adequate staffing levels in the service. The environment was well maintained, personalised, welcoming and adapted to suit people’s needs.

People were supported to have maximum choice and control of their lives and staff did support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice.

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

Rating at last inspection

The last rating for this service was good (published 12 December 2018).

Why we inspected

The inspection was prompted in part by 2 notifications of an accident and incident following which a person using the service died, and another person sustained a serious pressure area wound. These incidents are subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incidents indicated potential concerns about the management of risk of pressure area care, falls management and record keeping. This inspection examined those risks.

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

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe 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. The provider was responsive to inspection findings and action has already been taken to mitigate the risks identified.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for 'Cottingley Hall Care Home' on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified a breach in relation to good governance at this inspection. We also made recommendations in relation to medicine management. Please see the action we have told the provider to take at the end of this report.

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 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.