Collingswood 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

The key question of well-led was rated as good at our last assessment. At this assessment the rating has changed to requires improvement. Managers in the service were caring and supportive towards staff and the people that used the service. Staff were listened to and were supported in their roles by an approachable management team. Staff recommended the service as a good place to work. The relatively new management team worked closely together to cover all aspects of the delivery of the service. The management team led with integrity, and openness. The management team demonstrated their passion to improve the service and recognised there were areas that still needed further improvement. The service did not yet have an organised approach to assess and learn from feedback about the service. Staff training had improved recently with the arrival of a service training manager. There had been an increase in training that staff were required to do, and further training was planned. The service had grown considerably over recent years, and the management and coordination of the service had also grown over this period to deliver this larger service. However, the service had limited governance systems and issues such as the lack of MCA knowledge, had not been acted upon by the service management team. We found that there was a failure of governance and management in monitoring visit times. These issues contributed to a breach of regulation.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Most staff we received feedback from were positive about the leadership of the service and all said they felt the managers in the service were caring towards them and the people using the service. Staff told us they felt listened to and all said they were supported in their roles by an approachable management team. One staff member commented, ‘Collingswood have welcomed me into the company so gracefully. There is nothing I could not approach the company with, (name) the trainer is so knowledgeable. Rosterers, (name) and (name) are fantastic with my availability, (name) in payroll is amazing and always has such a lovely smile and is able to sort payroll issues before us staff have even realised, (name) the registered manager is simply fantastic, if I have any issues that I need to raise, he is always calm and approachable, and is often out on the road himself helping to cover runs. I could not ask for a better company to work for.’ Almost all staff said they would recommend the service as a good place to work. During the assessment the management team demonstrated their passion to improve the service and recognised there were areas that still needed further improvement.

The provider had employed a second registered manager. In addition, a deputy manager was also now in post. We found the management team led with integrity, and openness. The management team told us they were being supported by the provider. The service management and the staff spoke positively about the provider registered manager being in the service most days.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The management team told us about, and showed us, the records they kept. They also told us about how they managed the service. The service had grown considerably over recent years, and the management and coordination of the service had also grown over this period to deliver the larger service. However, it was noted that the service had no governance from outside the immediate management in the service. Therefore, the management team were wholly reliant on their own knowledge and experience, and so where they did not bring experience or knowledge with them into the service, they had gaps in their knowledge. For example, the use of the Mental Capacity Act 2005.

We found audit systems were generally in place for the service through their IT system. However, there was no audit system in place to routinely monitor the arrival and departure times of staff from care visits. This meant the management team did not know when visits had begun and ended and so could not identify when people’s visits were late, or had been cut short. The management of the service was also rostering staff visit times without adequate travel time between visits. This was a failure of the governance systems in the service. This contributed to a breach of regulation.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The management team had areas of improvement to make and there was not yet an organised approach to service feedback and learning. However, during the assessment, the service’s management demonstrated a wish to learn and improve the service. We spoke with staff about learning and improving care. Staff told us the training had improved a great deal recently with the arrival of a service training manager. Records showed an increase in mandatory training, as defined by the service, and further training had been booked.

The service had started to put systems and processes in place to continuously learn, innovate and improve. The service had asked people that used the service, their relatives and staff for their feedback, but they had not yet started to analyse this feedback. The experience of people using the service and their relatives, showed the service had yet to act on their feedback.