The Cottage Residential Care Home

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 good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

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

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

There was a lack of shared direction and cohesive culture within the service. There was little evidence of effective leadership guiding day-to-day practice. This absence of a clear, shared vision contributed to inconsistent standards of care, and a lack of accountability. Without a strong and inclusive culture, staff were not supported to deliver high-quality, person-centred care, and this placed people at increased risk of receiving care that did not meet their individual needs or uphold their dignity.

The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders did not have the skills, knowledge, experience and credibility to lead effectively.

The provider and registered manager of the service was no longer available to provide oversight at the service. Present at the service was 2 interim managers who were endeavouring to manage the service. These managers knew people very well and they told us that their intentions were always to try to provide safe care. However, there was a lack of understanding about the processes they needed to follow to keep people safe. The managers told us they had wanted to move people into more appropriate accommodation but they failed to follow the guidance they had been provided with, in relation to registration requirements and regulatory requirements.

We were not assured the managers present had the skills, knowledge or experience to provide safe care. They were not aware of requirements relating to specialised diets, medicine processes, safeguarding process, oversight of training, infection control, fire safety, safe storage of chemicals, legionnaires management or risk management.

We were not assured people or staff could speak up and that their voice would be heard.

The managers told us there were no complaints and whilst we could see staff knew people well, staff had not recognised the failings at the service. This meant we were not assured the staff were aware of the standards people should be receiving.

The provider service did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There was a lack of effective systems to promote equality, diversity, and inclusion within the workforce. There was minimal evidence of regular training or leadership oversight to ensure that equality, diversity and inclusion principles were embedded in recruitment, staff development, or day-to-day practice.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The managers could not provide us with all necessary information. For example, we were unable to see a valid public liability insurance certificate. The manager told us they had been assured by their insurance broker they were insured. However, all we were shown was an email from the broker with this information. The email was also requesting information from the manager for a new quote. We asked the manager to forward us this email trail to reassure us, however, this was not sent. The email was not clear if public liability insurance was valid.

Oversight of safety concerns recorded above such as fire safety, Legionnaires management, infection control, the environment, medicines and safeguarding were not effective.

There was no evidence of effective leadership or strategic oversight to ensure the service was operating safely, compliantly, or in line with regulatory requirement. Managers lacked the necessary skills and experience to identify and respond to risks, and systems in place were insufficient to monitor quality or drive improvement. Failure to maintain essential documentation in respect of safety further demonstrated a lack of accountability.

The service did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

Whilst we did see evidence managers had made referrals to other health professionals, they had not always followed the guidance which was received. Prior to the assessment the local authority had visited the service and were not assured the service was operating safely.

The service did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

There was little evidence that leaders used information from incidents, audits, or feedback to drive improvements. Systems to evaluate the quality of care and identify areas for development were either absent or ineffective. There was minimal evidence that managers had taken the necessary steps to improve their learning in relation to safety and regulatory requirements.