This inspection commenced on 2 May 2018 and was unannounced. This meant the provider and staff did not know we were coming. Two shorter visits were also carried out on 3 and 4 May which were announced.

At the last inspection of this service in January 2017 we found two breaches of regulations relating to staff recruitment checks and to the governance of the home. The overall rating for the service at that time was 'Requires Improvement'. During this inspection we found improvements had been made in relation to the breaches and significant improvements had been made across the service as a whole. The overall rating has improved to ‘Good'.

Morton Cottage Residential Home 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.

Morton Cottage Residential Home accommodates up to 32 people in one adapted building. There were 22 people accommodated at the home at the time of this inspection, some of whom were living with dementia.

The home had a registered manager who had been in this role for several 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.

All the people and relatives we spoke with felt the home was a safe and comfortable place to live. Staff were clear about how to recognise and report any suspicions of abuse. The provider carried out checks to make sure only suitable staff were employed. People were assisted with their medicines in a safe way. The home was clean and odour-free.

People told us they were happy with the care and felt there were enough staff to assist them. They told us staff responded quickly to any requests for support. People’s consent and permission was sought before staff carried out any care. If people were subject to any restrictions to keep them safe, such as bed rails, this had been arranged in people’s best interests. 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. The provider was seeking advice from the local authority about people who may be under constant supervision, including people staying for a short-break. We have made a recommendation about this.

Before people moved to the home their needs were assessed to make sure the home could provide the right care. Staff said they had good training and support to care for people in the right way. Staff worked well with other health agencies and people were supported to access health services.

Relatives said the staff cared for people in an effective way and responded quickly to any changes in people’s well-being. People were supported to have enough to eat and drink. People said the meals were very good and they had choices about their meals and where to dine.

The provider and registered manager made good use of technology to support the service. This included a computerised medication system, computerised care records and use of a call alarm system that alerted staff by pager.

People felt the staff were caring and kind. There were good relationships between people and staff and there was a warm, uplifting atmosphere in the home. Staff spoke to people in a positive and friendly manner. People’s individual choices were respected and their dignity was upheld. Staff spoke about people with compassion and were sensitive to people’s needs at the end stages of their lives.

People received personalised care that was based on their preferences and needs. Staff were knowledgeable about people’s individual care needs

The inspection took place on 9 and 10 January 2017 and was unannounced.

At our last inspection of this service in July 2016 we found breaches in nine of the legal regulations including regulations around safe care and treatment, safeguarding, staffing and good governance. The service was rated as Inadequate and was placed in ‘special measures’. At our most recent inspection of 10 January 2017, we found that the registered provider had made improvements and progress towards meeting the legal requirements, although there remained breaches of two regulations around staff recruitment and good governance.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Morton Cottage Residential Home is registered to provide care and accommodation for up to 32 mainly older people, some of whom may be living with dementia. Accommodation is provided over two floors in single bedrooms with en-suite facilities. There are further communal facilities such as bathrooms, toilets, sitting rooms and a dining room available.

There was a registered manager in post at the home. 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.

After our last inspection of this home, the registered manager sent us an action plan describing how things would be improved. The action plan included actions to be taken, timescales to show when the improvements would be in place by and who was responsible for the improvements.

At this inspection we found that the provider had taken action to make significant improvements to the standard of care and safety at Morton Cottage Residential Home.

On the day of our visit the home was clean, tidy and there were no unpleasant odours. The housekeepers and care staff spoke to us about the changes and developments that had taken place to promote good hygiene and reduce the risks of cross infection.

Some areas of the home had been redecorated and new furnishings were in place. Dark corridors had been enhanced by new and more effective lighting. However, adaptations and environmental improvements to help support people living with dementia were limited.

We have made a recommendation that the service seek advice and guidance in relation to environmental adaptations to help meet the specialist needs of people living with dementia.

We found that staffing levels and staff deployment had improved, although the registered provider did not yet have a system in place to ensure this was consistently maintained as people’s needs changed.

We observed some good interactions and friendly exchanges between staff, visitors and people who used the service. Staff supported people with their mobility and care needs in a safe manner and also ensured that privacy and dignity was not compromised.

We saw that meaningful activities had started to be introduced at the service. The registered provider was able to show us that a programme of activities and entertainments was being drawn up but this was in the early stages of development. During our visit we noticed that there were few items in the communal areas of the home, for example books, magazines or jigsaws that would have provided some alternative and independent activities for people using this service.

We have made a recommendation that the service seek advice and guidance from a reputable source, and based on current best practice, in

Morton Cottage Residential Home (the home) is registered to provide accommodation for people who require personal care. The home can accommodate up to 32 older people, some of whom may be living with dementia. Accommodation is provided over two floors in single rooms, but there are facilities for shared accommodation (2 rooms). All rooms have en-suite toilet and wash basin facilities. There are communal bathrooms and toilet facilities available throughout the home and a wet room has recently been installed at the service.

There is a registered manager in post at the home. 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.

This inspection took place over three days, 27 and 28 July and 11 August 2016. The inspection was unannounced.

We had previously carried out an unannounced comprehensive inspection of this service on 29 September 2015. Eleven breaches of the legal requirements were found. We judged that this service was “Inadequate” and Morton Cottage Residential Home was placed in special measures. We issued eleven requirement notices to the provider.

Requirement notices were issued as people who lived at the home did not receive respectful and dignified care or appropriate care and treatment that met their needs and reflected their preferences. People were at risk from unsafe practices relating to the control of infections and contamination, of having unlawful restrictions placed on their liberty and at risk as their nutritional and hydration needs were not met. People who lived at the home did not receive their care and support from people who had the skills, competence and experience to do so safely. The management of the service was not open and transparent, with no clear lines of accountability in place. There were no systems in place to effectively monitor and improve the quality and safety of the service and to ensure compliance with the requirements. The registered provider sent us an action plan to show how they would ensure compliance with these parts of the regulations.

Our unannounced inspection on 27 and 28 July and 11 August 2016 was a full comprehensive inspection. We found that improvements had not been made and breaches of the regulations continued. People who lived at the home did not receive care or treatment that had been personalised specifically for them. This placed people at risk of receiving care or treatment that did not meet their individual needs or expectations.

People who lived at the home did not receive care and treatment that ensured their dignity or treated them with respect. Procedures for obtaining consent to care and treatment did not always follow current legislation and guidance. This meant that people who used this service were placed at risk of receiving care or treatment that they had not agreed or consented to.

People who lived at the home were not protected from the risks of receiving unsafe care, treatment and avoidable harm. Medicines were not managed safely and people were placed at risk of not receiving their medicines as prescribed.

There were no systems in place to ensure people were protected from the risks associated with infection prevention and control. The premises were not clean and properly maintained. Equipment was not used properly or safely.

People who lived at the home were not always protected from the risks of abuse and improper treatment. The provider did not have effective systems and processes in place to monitor and assess the quality and safety of the service. This meant that the provider had no way of checking that they were keeping people safe or meeting the requirements of the regulations.

People were not provided with adequate support with their nutrition and

We visited the home on 29 September 2015. The inspection was an unannounced scheduled inspection visit.

At the last inspection on 18 November 2013, we asked the provider to take action to make improvements to the ways in which records were maintained and to the ways in which the provider assessed, monitored and improved the quality of the service. The provider submitted an action plan which stated that the legal requirements would be met by the end of March 2014. We found during our latest inspection, that this had not been completed.

Morton Cottage Residential Home is a large house within private grounds, situated in a residential area of Carlisle. The home is registered to provide accommodation for people who require personal care. The home can accommodate up to 32 older people, some of whom may be living with dementia.

Accommodation is provided over two floors in single rooms, but there are facilities for shared accommodation (2 rooms). All rooms have ensuite toilet and wash basin facilities and communal bathrooms and toilet facilities are available throughout the home.

There is a registered manager in post at the home. 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 spoke with people who used this service and to some of their visitors. They told us that the staff were “nice”, “kind” and that “no one was nasty” to them. The relatives we spoke with told us they could “come and go” as they pleased and that they had never seen anything at the home to “worry” them. One person commented; “I can’t fault it here, they look after us and visitors can come when they want, they are not strict like that.”

Allegations of potential abuse and safeguarding had not been managed consistently. This meant that people who used the service had been placed at risk of harm and abuse.

This is a breach Regulation 13 of the Health and Social Care Act (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

People’s medicines were not stored and disposed of safely. This meant that people had access to medicines that were not theirs and had not been prescribed for them, placing them at risk of harm.

This is a breach Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Where risks to the health and safety of people using this service had been identified, the provider had failed to keep these under review and up to date in order to mitigate any such risks. This meant that people were not properly protected from the risk of harm or injury.

This is a breach Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

We found that the provider had not ensured that the premises were safe and secure. Windows on the first floor did not have restrictors in place and this was a risk to the safety of people living at Morton Cottage. Additionally, we observed poor infection control and prevention practices by staff during our visit to the home. This meant that people who used this service were placed at risk of acquiring infections.

This is a breach Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The staff that we spoke with told us about the training and support they were provided with. We observed examples of staff practices during our visit to this home. We found that there were shortfalls in their skills and knowledge.

This is a breach of Regulation 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014 because lack of staff skills and knowledge placed people at risk of harm or of receiving inappropriate care. You can see what action we told the provider to take at the back of the full version of the report.

Although staff had received some training about the Mental Capacity Act 2005 we found that there was a lack of understanding. We noted that the principles of the Mental Capacity Act 2005 Code of Practice had not been followed when assessing people’s ability to make a particular decision or when placing restrictions on their liberty.

This is a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This meant that people who used this service did not always receive care and treatment that had lawfully been provided in their best interests. You can see what action we told the provider to take at the back of the full version of the report.

People were provided with meals and drinks, which they told us they enjoyed. On the day of our visit we noted that mealtimes were not a sociable or dignified event. We also found that people’s nutritional needs were not adequately assessed and monitored, where necessary.

This is a breach of Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This meant that people who used this service were placed at risk of poor or inappropriate nutrition. You can see what action we told the provider to take at the back of the full version of the report.

Staff were inconsistent in the way they supported people with their personal care needs. Some needs were dealt with discreetly whilst other staff lacked understanding of how to support people and communicate with them effectively. We did not receive any complaints about the service but we did notice that many of the people that lived at Morton Cottage appeared unkempt and needed their hair brushed or items of clothing changed.

This is a breach of Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This meant that people who used this service were not always offered the support they needed to maintain their dignity. You can see what action we told the provider to take at the back of the full version of the report.

People told us, and we noticed that there were very limited social and leisure activities available at the home. We were told of some events that had taken place and people told us that they had enjoyed these “very much”.

Care and support records were out of date and staff told us that they didn’t always read them. We saw some examples where people did not get the care and support they needed, when they needed it.

This is a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People did not experience care and treatment that had been personalised specifically for them. You can see what action we told the provider to take at the back of the full version of the report.

There was no effective system in place to help monitor and manage the quality of the home and of the service provided. Personal records were out of date and environmental audits had not taken place.

This is a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This meant that the provider did not have systems in place to ensure the safety and quality of the service. You can see what action we told the provider to take at the back of the full version of the report.

We have made a recommendation that the service attends to the access arrangements for the home, including the provision of a contact telephone number. This will help ensure that visitors to the home are able to gain access to Morton Cottage.

Safe recruitment processes were in place to help ensure suitable staff were employed to work with people who used this service. There was a low staff turnover and this meant that staff and people who used this service got to know each other very well.

The home had not received any concerns or complaints about the service provided. No one raised any concerns with us at the time of our visit to the service. We checked the information we held about Morton Cottage Care Home. This also showed that we had not received any complaints about the service.

There were some positive aspects to the environment at the home. Individual bedrooms were spacious and all had en-suite facilities. Some floorings and furnishings had been replaced in communal areas, helping to make them pleasant.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special Measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

We found that people who used this service had received an assessment of their care and support needs and that they, or their relatives, had been involved with this process. The care needs assessments had provided information to help with the development of people’s individual personal care plans.

We observed staff supporting people with their day to day needs. We saw that where possible, people were encouraged to do things for themselves. Staff treated people in a dignified and friendly manner. We observed and heard the good rapport between staff and people who lived at the home.

We found that although the provider had systems in place to monitor the quality of the service provided thorough audits and checks had not been carried out for some time. During our inspection we found areas for improvement that would have been identified if the auditing system had been maintained and effectively implemented. For example, record keeping and notifying CQC about adverse events at the home.

We noted improvements in the general environment at the home. New seating, dining tables and chairs had recently been purchased and the provider told us of the plans to purchase new profiling beds over the next twelve months.

The people we spoke to during our visit to Morton Cottage were all very happy with the home and the service they received. People told us;

“I am very satisfied. The staff are excellent. I don’t need much help but they (the staff) are always there if I need them.”

“If I have any concerns the staff will listen and do something about it. They have been very good and I have no complaints.”

“It’s homely here and very nice.”

“The carers are lovely girls and very helpful.”

During our inspection we spoke with people about what life was like at Morton Cottage. We spoke in detail with four residents, a relative, three members of care staff and the home owner. Everyone provided us with positive feedback. We also observed the care being given and the interaction between care staff and residents.

The Local Authority (LA) had received some concerns regarding inappropriate moving and handling techniques, and a lack of pressure relieving equipment and had visited the home earlier in the year. They had found a lack of aids to prevent pressure sores such as special cushions and chairs (although it was noted that there were no residents with any pressure sores), the need for additional training around moving and handling, and the need for more detailed documentation around the care of some residents. It was evident that the home had taken on board the advice the LA and the occupational therapist had given the staff as these areas were not found to be of concern during our inspection.

People told us they were able to make decisions about what they wanted to do and said their privacy and dignity was maintained at all times. They felt independence was promoted whenever possible and they liked the staff team and had confidence in them.

Comments from people living at the home included:

"They are lovely girls (the staff) they work hard but can’t do enough for you.”

“I can’t grumble everything is fine.”

“I wouldn’t want to be anywhere else except maybe at home but I can’t be there.”

“There is plenty of food and choice; if you don’t want to do something then that isn’t a problem.”

“It’s wonderful, the carers are so lovely and helpful.”

“I came in as respite three years ago and when I needed to again I chose to come back.”

A relative told us; “I am not aware of any problems, the staff seem lovely. My relative seems very well looked after and she never has anything negative to say about the home.”