Cockington House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant there were widespread shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider was in breach of a legal regulation in relation to the governance of the service.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was not a shared direction for the management and staff team to ensure each individual person was at the centre of their support when decisions about their lives were being made. Closed cultures were not an active discussion, for example during team meetings, so if they started to develop, they may not be quickly identified due to the lack of the team’s awareness of this issue.

Whilst there was no evidence of an organisational shared direction and culture staff did have views on this. One staff member told us, “Supporting residents and making sure they are well looked after and have a good person-centred plan, and we are advocates for their daily life.”

The service had experienced changes in the management team, but the current home manager and regional manager were open and honest about issues discussed with the inspection team.

The manager was compassionate and staff felt supported. The inspector spoke with the manager and regional manager about support for the manager to further develop in their new role and build on the skills they needed to effectively lead the team and focus on how they could enable people to live a good life as part of their community.

One staff member said, “[Manager] is very easily accessible, has the door open, circulates around, doesn’t hide away in the office. She’s very easy going, plays a very good managerial role but also a very good colleague as on the floor and always around, it’s a very friendly atmosphere.”

People did feel they could speak up and that their voice would be heard but policy to support this was not up to date to signpost people to the right external agency or internal processes to support this. The policy documents were updated during the inspection process to ensure people had access to the right information.

One staff member said, “You can speak up about any issues, concerns or worries, you shouldn’t feel you should hold back which I don’t, any problems always gone straight to the manager.” Staff were aware of who to escalate concerns to if they needed to.

Complaints were investigated but this was not effectively documented or in line with the provider’s policy which was discussed with the management team. There was a copy of the home’s complaints policy available for people in an accessible format.

We did not find any evidence of issues about the fair and equitable treatment of staff. Staff we spoke with did not highlight any concerns about this. One staff member spoke with us about their hours of work and indicated that they were not asked to work too many hours as this would impact their wellbeing.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

The care plans were not reflective of current best practice guidance right support, right care, right culture and the risks associated with out-of-date models of care had not been effectively addressed.

We saw evidence of risks identified but not addressed including significant risks that had not been identified which were highlighted during the inspection. The provider was responsive to concerns however there was a lack of robust governance process and defined roles to carry out these activities which was a barrier to proactive management and identifying issues of concern.

The provider did understand their duty to collaborate and work in partnership, so services worked seamlessly for people. However, there was no evidence to support collaborative work to support improvement or how the provider had engaged others so people could thrive, develop skills, have new experiences and live the life they choose.

We saw that people did have hospital passports to support the person with transition should they need to be admitted to hospital, but the passports lacked some essential details. For example, one person who has a modified diet to reduce the risk of choking had a hospital passport that lacked details about this.

We did see that people were supported to access health services and it was recorded when people had attended appointments with professionals to support with their health and wellbeing.

The provider did not always focus on continuous learning, innovation and improvement and encourage creative ways of delivering equality of experience, outcome and quality of life for people.

At the inspection carried out in September 2023 it was identified that quality assurance processes were not in place which was a breach of Regulation 17 Good Governance. The provider and management team had failed to learn from this process and improve ways of working and continued to lack these essential systems to provide assurance of quality of care and opportunities for improvement. The provider remained in breach of this regulation.