Coton 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 Good. At this assessment the rating has changed to 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 governance at the service.

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.

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. The provider had a vision which was outlined in the statement of purpose. The vision document described the vision and included references to staff developing the required skills. However, we found the systems in place to ensure staff training remained up to date and included all areas had not been effective. For example, records showed staff had training in epilepsy awareness, moving and handling and deprivation of liberty safeguards was overdue for a refresher course.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. Leaders did not always ensure people received the support they needed, have their rights protected and gave consent to their care. For example, although there were some mental capacity assessments carried out for specific decisions, assessments for the use of CCTV cameras were not done. The Deprivation of Liberty Safeguards (DoLS) were not person centred and did not address the use of bed rails and bed sensors in their applications. The registered manager has told us since the inspection all residents care plans have been updated to reflect this. The oversight system in place to ensure peoples risk assessments and care plans were accurate had not identified where these were incorrect. For example, care plans were audited on a percentage basis therefore issues with a person’s daily glucose readings were not identified. The registered manager has since told us that the management team will have daily oversight of daily glucose level readings for people. A guidance has been developed for the care team. The registered manager told us has also told us a meeting and supervision sessions are planned with all senior team members. However, staff told us the management team was supportive and approachable. The provider had systems in place to ensure staff were supported. Systems were in place to ensure staff were supported. We saw regular supervisions and 1:1 support provided to staff. The management team were open, honest and responsive to our findings throughout our assessment and were aware of the improvements needed to systems and processes to improve the quality of the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. A person told us, “The registered manager is polite and caring but you don’t see them that often. If I had any concerns, I feel that I could raise them, but I haven’t got any.” A relative told us, “I haven’t had to raise any concerns, but I have asked questions, mainly about systems, and they have been very thorough. Staff told us they knew how to raise concerns and felt they would be listened to. The registered manager understood the duty of candour and their responsibilities. The provider had a policy in place to support staff to raise concerns, have freedom to speak up and whistle blow. The policy gave guidance to staff on how to raise concerns and assurances these would be taken seriously and investigated appropriately.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider had a policy in place to support equality and diversity. The policy set out to ensure all staff worked in an environment which was free from harassment and discrimination. The policy set out how staff would receive equal treatment regardless of their protected characteristics in all aspects of their employment.

The provider did not have effective oversight systems in place to provide good governance. There were some audit systems in place to check on the quality of the service, however these were not always effective in identifying areas for improvement and driving change. The medicines audits had not identified the lack of PRN protocols, when actions were not taken to address missing signatures or when stock records were inaccurate. This meant the process was not ensuring people received their medicines as prescribed. The building oversight systems had not ensured all window restrictors had been reviewed to see if they met current guidance, we saw audits had taken place for window restrictors. We saw radiator covers which required a repair. Since the inspection the provider has addressed this issue and have repaired the radiator covers. However, we saw there were other audits in place such as mattress, bed rails, pressure relieving equipment, advocacy, walking frame, catering, health and safety, sling and night audits. We saw there were adults in place for medicines but this did not identify the discrepancies in the stock count and missing signatures.

The provider did not respond in a timely way to learning shared by partners to make improvements to the service. Partners told us the provider worked openly with them as commissioners. They told us they had given an action plan to the provider following a quality audit carried out by commissioners. We saw the audit had identified improvements were needed and these had been shared with the provider. However, many of the concerns we found on the inspection site visit had been identified in this audit 6 months earlier, but not all actions had been addressed. This meant we could not be assured the provider was taking action when partners had identified areas of improvement.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. There were systems in place to monitor quality and inform learning and improvements.The manager was engaged and proactive in ensuring the service continually improves.