Cockington House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not demonstrate a consistently proactive or positive culture of safety. Systems and behaviours that support openness, honesty and continuous learning were not fully embedded. As a result, opportunities to learn from incidents and strengthen safe practice were missed.

At our previous assessment, we identified that the registered manager had not recognised safety risks within the environment. Although they gave assurances that more robust monitoring and checking processes would be introduced, we found these improvements had not been implemented.

The failure to adopt a learning culture, and to take timely action when concerns were identified, meant lessons were not embedded in day‑to‑day practice. This placed people at ongoing and avoidable risk of harm.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always ensure people’s rights to live safely and free from abuse, neglect, discrimination and avoidable harm were upheld. Systems intended to identify, report and respond to safeguarding concerns were not applied consistently, and concerns were not always shared promptly or appropriately with relevant agencies.

Safeguarding concerns were not consistently recorded. Where issues had been identified, records did not always include clear documentation of the concern, the outcome, or any actions taken to prevent recurrence. Some entries were incomplete or undated, which meant it was not possible to establish an accurate timeline or assess whether action had been appropriate or timely.

We found that not all people were supported to engage in meaningful activities inside or outside the home. The lack of regular mental and physical stimulation placed people at risk of social isolation and deterioration in their mental wellbeing. It also increased the likelihood of people experiencing distressed behaviours linked to unmet needs or insufficient stimulation.

The provider took action to address this concern and introduced weekly activity planners, designed to ensure people had access to a balanced, sustainable routine of meaningful activities. However, during our assessment we found these planners were not consistently followed in practice, and people were still not receiving the level of engagement and stimulation outlined in their care plans. This lack of meaningful activity constituted neglectful care and did not protect people from avoidable harm.

The provider did not always work effectively with people to understand and manage risks to their health, safety and wellbeing. Staff did not consistently provide care that was safe, supportive or enabled people to take part in the activities and routines that mattered to them.

Some people living at the home were not able to express their views about this aspect of their care. To understand their experience, we used observations and reviewed care documentation. This helped us assess whether people’s needs were being met and whether they were being supported to engage in what was important to them.

At the last assessment, the registered manager acknowledged that there were gaps in the team’s knowledge and stated a commitment to improving this. However, during this assessment we found no evidence of actions taken to enhance staff skills or knowledge to support safe, informed risk management.

Monitoring tools, including ABC charts, were not completed accurately or in full. An ABC chart helps us understand behaviour by noting what happens before, during, and after it.
It’s a simple way to spot patterns and figure out how to help someone better.

Records lacked detail and were not reviewed in a meaningful way to help identify patterns, inform risk assessments or guide staff in how best to support people safely.

This lack of understanding of people’s individual needs and risks meant people were notconsistently supported in a way that promoted their safety, independence or ability to engage in the things that mattered to them.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The provider had made improvements in the physical environment since our last assessment including correcting environmental factors impacting fire safety.

However, information regarding fire evacuation drills was not consistent with feedback from staff about this being carried out which did not provide assurance regarding fire safety. One staff member said, “We do online training, no evacuation is completed.”

There were health and safety audits implemented in July 2025, but we noted audits were not consistently signed or dated. They did not always pick up on areas that required improvement, and when they did it was unclear what action had been taken.

Maintaining a safe environment is vital for the safety and welfare of people living in the home and failing to do this placed them at risk of harm

The provider did not consistently ensure there were enough suitably skilled, experienced and competent staff to meet people’s needs safely. Staffing arrangements did not always support effective teamwork or enable staff to deliver care that reflected people’s assessed needs and individual support requirements. Staff were not always provided with effective supervision, support or ongoing development to maintain and strengthen their skills.

Staff we spoke with told us they cared about the people they supported and wanted to deliver safe, high‑quality care. However, they were not consistently supported by the registered manager to do this.

Although staff reported that there were enough people on shift, they were not always able to distinguish between standard staffing levels and those commissioned to provide enhanced or one‑to‑one support. This created a risk that people who required higher levels of supervision or personalised support did not consistently receive the care they had been assessed as needing.

Feedback about supervision was inconsistent. Some staff told us they received regular one‑to‑one meetings with the registered manager, while others said they had not received supervision for some time. We reviewed team meeting minutes and found no clear evidence of continuous learning or improvement being discussed. The tone of the documentation was largely negative and did not identify positive practice, feedback or learning opportunities. The most recent set of minutes was undated, which meant we could not determine how current they were.

This lack of structured supervision, team‑based learning and performance oversight meant opportunities to identify staff development needs or drive improvements within the home were missed. As a result, people did not consistently receive safe and effective support from a well‑led, well‑trained staff team.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We identified similar concerns as found on the previous assessment around the environment.

Issues previously identified around maintaining a hygienically clean environment had not been fully addressed. For example, lights with pull cords were not all covered with a plastic casing so they could be kept hygienically clean. We also found discarded furniture in the garden, blocking access to the fire escape ground. The provider took immediate action and had the furniture removed from the garden.

Failing to maintain a hygienic environment placed people at risk of infection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

We found medicines records were not completed appropriately for people receiving ‘as required’ medicines to demonstrate that medicine achieved the required outcome for people. For example, where people had received medicine for agitation, there was no detail on why this had been given or the effect that the medicine had had.

This meant people were at risk of not receiving the correct medicines when they were needed to maintain their health and wellbeing.