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 service 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 the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance at the last assessment. The service remained in breach of this regulation. We have asked the provider to embed the action they are taking, and we will revisit to assess compliance.

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.

The provider did not demonstrate a clear or shared vision, strategy or culture that promoted transparency, equity, equality, human rights, diversity, inclusion or meaningful engagement. Leaders did not always demonstrate an understanding of the challenges within the service or the needs of the people and communities they served.

Staff were unable to clearly explain the service’s vision and values. Supervision and training arrangements were not always effective in supporting staff to understand the people they cared for or the wider community context of the service. As a result, staff were not always equipped with the knowledge or skills needed to deliver care in line with best practice or with people’s individual needs.

Staff raised concerns about the overall culture and leadership within the service. They did not feel there was a collaborative culture where staff and people were listened to, valued or engaged in discussions to promote learning or improvement. It was unclear how audit findings, incidents or lessons learned were communicated across the staff team to support improvement and enable staff at all levels to work well together.

The nature of the concerns raised indicated features of a closed culture. A closed culture is defined as one where poor practice becomes normalised and can lead to harm, including breaches of human rights. In such environments, the risk of both deliberate and unintentional harm to people is increased.

We shared our concerns with the provider’s senior leaders. The provider and regional manager acknowledged the issues identified and assured us that action would be taken to support the registered manager and drive the required improvements within the service.

Not all leaders demonstrated a clear understanding of the context in which the provider delivered care, treatment and support. Leaders did not always model the culture and values expected within the organisation. We found that some leaders did not have the necessary skills, knowledge, experience or credibility to lead effectively, and they did not always do so with integrity, openness or honesty.

The registered manager had a job description that clearly outlined their responsibilities. However, our review of records and feedback gathered during the assessment indicated these responsibilities were not consistently fulfilled.

Staff we spoke with confirmed there had been some improvements, particularly in relation to the provision of person-centred activities since our visit. One staff member told us the manager had recently been more supportive of their personal circumstances. However, they also said this support was not consistent, and they did not always feel able to be open or honest in their feedback for fear of negative consequences for their role.

The provider acknowledged the concerns identified and committed to ensuring the regional manager would offer additional oversight and support at the home. This was intended to strengthen leadership capacity, address identified issues, and support the registered manager’s development. Leaders recognised that improving leadership capability would have a positive impact on both people living at the home and the staff team.

People did not always feel confident that they could speak up or that their concerns would be heard and acted upon. Although people living at the home and their relatives told us they felt able to raise issues with staff and the registered manager, staff themselves did not feel they had the same freedom. Staff consistently reported poor communication between the registered manager and the staff team, and they did not feel listened to when raising concerns or offering suggestions for improvement.

Several staff told us they lacked confidence that issues they reported would be acted on, and some did not feel able to be open or honest for fear of negative consequences. This created a barrier to open communication and reduced opportunities for learning and improvement within the service.

We reviewed records where relatives had raised concerns. Although the provider had responded, the actions taken did not always meet the requirements of the duty of candour. When something had gone wrong, people did not always receive a sincere and timely apology, nor were they consistently informed about what actions were being taken to prevent a recurrence. This meant people and their families were not always treated with openness or transparency following an incident.

When people feel unable to speak up, risks may go unreported or unaddressed, which reduces opportunities to prevent harm.

The provider did not always demonstrate that they valued diversity within their workforce or actively worked towards creating an inclusive and fair culture. Leaders did not consistently promote equality or equity for staff, and not all staff felt supported or treated in a way that reflected the provider’s stated values.

Staff told us they did not always feel they were treated equally or fairly. Several staff raised concerns about their wellbeing, including the number of hours they were required to work. Some staff reported feeling unable to speak up about this and described working additional hours to ensure people received the care they needed, even when this had an impact on their own health and work–life balance. Staff also raised concerns about relationship dynamics within the team, which led some to feel they were treated less favourably than others.

People told us the provider had made reasonable adjustments for some staff, such as offering time out or altering shifts to support individual needs. However, these adjustments were not always reviewed appropriately to ensure they remained suitable, effective or sustainable. This meant that reasonable adjustments were not consistently monitored or adapted in response to changing needs.

The provider had policies in place relating to equality, diversity and inclusion, and staff completed diversity questionnaires as part of the onboarding process at recruitment. However, these processes were not always translated into meaningful actions or a culture that ensured all staff felt valued, included or supported.

Overall, the workforce culture required improvement to ensure staff felt respected, treated fairly and empowered to raise concerns.

The provider did not have consistently effective governance arrangements in place. Systems designed to monitor the quality and safety of the service were not always robust, and leaders did not consistently act on the best information available about risk, performance or outcomes.

Although the provider had clear job descriptions for all staff, outlining defined roles and responsibilities, these were not always adhered to in practice. Staff did not consistently take accountability for their individual responsibilities, which resulted in important tasks being missed or not completed to the required standard.

Some of the provider’s governance systems and ways of working were ineffective. Audits of care plans and medicines records had failed to identify errors. Where audits had highlighted concerns, there was insufficient evidence to demonstrate whether actions had been taken, or how issues had been resolved. This limited the service’s ability to learn, improve, and prevent repeated mistakes.

We found three safeguarding folders on site. However, most of the information held within them was significantly out of date. This meant leaders did not have easy access to accurate, up‑to‑date safeguarding records, increasing the risk that safeguarding concerns might be managed inconsistently or without appropriate oversight.

The weaknesses identified in governance meant that issues affecting the quality of the environment, inaccuracies within care plans and risk assessments, and errors in medicines records were not always identified or addressed by the registered manager. These gaps increased the risk of harm to people using the service.

The provider submitted an action plan setting out how they intended to improve governance processes and strengthen management oversight across the service.

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 provider did not always demonstrate a strong focus on continuous learning, innovation or improvement across the organisation or the wider local system. Leaders did not consistently encourage or support creative approaches to delivering equitable experiences and outcomes for people, or to improving people’s quality of life. The provider was not always proactive in contributing to safe and effective practice.

The registered manager had not sufficiently learned from the findings of the previous CQC assessment. Actions required to address previously identified concerns had not been implemented effectively or sustained. As a result, similar issues were identified during this assessment, indicating that lessons had not been embedded and improvements had not been achieved.

The regional manager had recently begun working with the registered manager to introduce new ways of working aimed at strengthening management oversight, documentation and day‑to‑day practice at Cockington House. This work was at an early stage and had not yet resulted in demonstrable improvements.

Strengthening governance systems, improving documentation and embedding consistent, effective practices will support positive changes in the quality of people’s care and their overall experience of living at the home. Sustainable improvement will depend on leaders committing to a culture of continuous learning and innovation.