Corbrook Park

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 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 provider was in breach of the regulations relating to good governance.

This service scored 57 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

One staff member stated they worked with a ‘such a good team especially between the care and nursing staff’ and another staff member said, “I believe in (manager) and they are the main reason why I am staying.”

The manager told us they felt supported by the provider and was working hard to make improvements in this area.

Whilst 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. Feedback from staff was mixed regarding communication from leaders. One staff member told us, “They have groups where information is shared and there is no unity. It is sad, our common goal is to care for people and anything to do with the residents we all need to know.” However, other comments included, “They lead by example” and “(Manager) has already sorted some issues out.”

Most staff stated both the manager and deputy manager were visible and approachable. The manager was working hard towards ensuring all staff felt included.

Whilst there were mechanisms in place to seek feedback, we received mixed feedback from staff when speaking up. Some staff did not feel listened to when they had previously spoken up. One staff member told us they were scared to speak up and another staff member told us they felt meetings were just for being ‘told what to do’ and previous concerns were ‘not heard and don’t go anywhere’. However, some staff stated they could speak up and would go directly to the manager. One staff member said of the manager “She is listening, and I am starting to see those changes.”

The manager was being proactive in embedding positive changes by having an open door policy and told us, “More and more staff feel confident to come to me.”

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Some staff felt they were treated differently. Comments included, “Some staff can pop into the office yet some staff need appointments,” and “One staff member is wished happy birthday [when others are not], babies have been born and nothing is said, then one person has a baby and it is mentioned [on social media]. It sends the wrong message.” This was shared with the provider who did not provide assurances on the implications this could have on staff morale.

However, some staff felt there were no concerns and were treated fairly. The manager confirmed reasonable adjustments had been made for some staff and told us, “The team is diverse and that’s what makes it great.”

The provider did not always have clear roles, line of responsibility, systems of accountability or good governance. They did not act on the best information available to them about risk, performance and outcomes. For example, issues identified in medicines and infection prevention control audits were not rectified in a timely manner. We identified concerns in relation to the provider’s systems and processes being effective in medicines management. For example, medicine error reports did not accurately identify concerns meaning the provider did not have clear oversight to mitigate future risks. The provider had various methods to capture feedback from visitors and dealt with formal complaints separately, however, not all concerns were dealt with effectively. For example, in a survey from July 2024 concerns around call bells, staffing levels and cleanliness were identified and were still ongoing during this inspection.

Business continuity plans were in place and the provider made statutory notifications.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Referrals to external professionals were evident in people’s care records. For example, GP and dietician. One health professional told us, “We are always looking at ways to improve the care being delivered to the residents.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe and effective practice. For example, audits and feedback from relatives highlighted areas for improvement. These were not always actioned in a timely manner and areas for improvement were still identified at the time of our assessment.