Cognacity

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

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.

This is the first assessment for this newly registered service. This key question has been rated requires improvement.

The service was in breach of Regulation 17 Good governance. The provider had not established effective systems and processes to assess, monitor and improve the quality and safety of the service.

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

This service scored 50 (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 demonstrate 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.

It was not evident if the leaders had successfully communicated the provider’s vision and values to all staff. Company vision was included in the induction for administrative staff, however not for other staff groups such as clinicians. Regular meetings were limited mostly to the senior management and clinical peer groups, and their minutes did not document discussions about vision, values or strategy. It was not clear how the provider monitored its progress against these. Because the provider had not ensured that all staff participated in regular meetings or managerial supervision, staff had limited opportunities to contribute to discussions about the service strategy and their role in achieving it.

Staff we spoke with understood the aims of the service and the provider’s commitment to providing a professional and responsive service to patients. Staff spoke positively about the friendly and supportive team culture.

Not all leaders understood the context in which the service 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, or they did not always do so with integrity, openness and honesty.

The service was led by a senior management team which included a Chief Executive Officer who was also the Nominated Individual, a Registered Manager who was also the operational manager and the Directors of the Group Board. Although the leaders had the qualifications and skills to perform their roles, they did not demonstrate a good oversight of the service they managed. During our inspection we found significant shortfalls related to the quality and safety of the service which the leaders had overlooked. These included medicines management, risk management, safeguarding, incidents, record keeping, environmental checks and policies and procedures. These are discussed in more detail in other sections of this report.

However, staff we spoke with told us that leaders were visible in the service, supportive and approachable.

Not all groups of people always felt they could speak up and that their voice would be heard.

We spoke with 8 patients and 5 carers. Seven people told us they had not had the opportunity to give feedback on the service they received. Two people said our inspection was the first time they had been asked for feedback.

However, staff we spoke with said they were comfortable to raise concerns with the leaders, should they need to. Overall, 90% of staff had completed the mandatory Whistleblowing (Speak Up) training. The service had appointed an external Freedom to Speak Up provider.

Managers carried out annual patient and staff surveys. We reviewed the results of the most recent patient survey from July 2025. Leaders had planned several actions in response to some of the feedback received. A staff survey was carried out in July 2025 and identified some actions, including ‘you said, we did’ feedback to be provided to staff. At the time of our inspection, these were in progress. Since concluding our inspection, we heard that the feedback and actions had been shared with staff.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The provider’s policy for recruitment and selection of staff outlined an anti-discriminatory approach. Staff received mandatory training in equality and diversity and 95% had completed it.

Staff we spoke with told us they were able to apply to work flexibly, for example due to caring responsibilities. Staff did not raise any concerns about discrimination.

The service shared information aimed at making staff included and welcomed, for example those with protected characteristics under the Equality Act 2010. The quarterly staff newsletter included stories shared by staff from diverse backgrounds.

The provider carried out a staff survey, although it did not monitor if staff felt that they were being treated equally and fairly irrespective of protected characteristics.

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 leaders did not demonstrate a clear understanding or oversight of the service they managed. Our inspection highlighted significant shortfalls in several areas. These included medicines management, risk management, safeguarding, incidents, record keeping, policies and procedures, and environmental checks. Because the provider had not established appropriate governance structures to monitor and improve the service, the leaders had failed to identify those gaps.

Staff undertook some local audits, however these were not sufficient to provide comprehensive assurance about the quality and safety of the service. For example, leaders told us that 6-monthly controlled drug (CD) audits were completed. However, only one annual CD audit was completed in April 2025. There were no audits of key areas such as risk assessment, care planning, medicines optimisation or record keeping, to ensure that care provided was safe and in line with the current guidance. A one-off safeguarding audit was undertaken in March 2025, which identified actions with no evidence of these being followed up. We saw repeated themes identified from complaints related to record keeping, and several instances where staff and leaders had not followed the provider’s own policies in managing incidents and complaints. This meant that potential risks were not identified or mitigated, and improvements not made where needed.

The potential risks extended beyond the provider’s patient group. The provider’s lack of robust oversight of controlled prescription stationery increased the risk of avoidable harm due to its misuse or diversion in the wider community. We saw no evidence of discussions around safe storage of prescribed medications that may cause serious harm if accidentally ingested by children.

Some of the provider’s key policies and procedures did not reflect the current national guidance or contained inaccurate information. These included the medicines management, serious incident and safeguarding policy and provider’s procedures for its doctors. The provider had not ensured that an appropriate range of policies and procedures was available for staff to refer to. The provider did not have policies to outline the treatments offered, mental capacity, consent, and staff training requirements.

The service held a quarterly quality assurance and governance meeting. We reviewed the minutes of this meeting. Its agenda was limited and did not include key topics such as safeguarding or lessons learnt from incidents. Staff we spoke with were not able to share any recent examples of learning from incidents. Other meetings held within the service were mostly limited to clinical peer groups and senior management.

Leaders did not understand the arrangements required for working with other teams, both within the provider and external, to ensure safety and continuity of patient care and treatment. The provider had no system in place to ensure regular communication with other professionals involved in patient care, such as GPs or dispensing pharmacists. There were no regular multidisciplinary team (MDT) meetings for all staff. Some staff shared their concerns about the lack of forums to discuss issues related to patient care.

The provider had not ensured that all staff received managerial supervision. This meant that managers may not be able to identify support needs or poor performance and deal with it promptly and effectively.

The provider’s information governance systems raised some concerns about the security of patients’ data (known as health data). The system for monthly reconciliation of prescription records relied on prescribers using their personal smartphones to record, store and send images of patients’ prescriptions. Whilst we heard that the leaders asked individuals to delete these images from their devices upon reconciliation, the provider had not embedded sufficient safeguards to ensure that patients’ data was stored securely and with appropriate informed consent in place. This increased the risk of patient confidentiality being compromised through unauthorised access or sharing.

The service had a risk register which detailed a range of risks specific to the service and mitigations for these. However, it did not reflect the risks highlighted during this inspection.

However, some governance processes worked more effectively. Leaders monitored the completion of mandatory training and appraisal and compliance with employment checks. The service had a plan for emergencies to ensure business activities could continue.

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

Staff did not always involve the necessary health and social care services to ensure safety and continuity of care. For example, we saw limited evidence of the service working proactively with the local authority safeguarding team following a referral made. Although staff informed NHS England of the loss of controlled prescription stationery within the service, this was done with a significant delay. This was not in line with the best practice guidance and meant that information was not shared locally to prevent the risk of fraudulent activity.

The service did not maintain records of dispensing pharmacies when prescribing controlled drugs to patients. This meant the service would not be able to contact the pharmacy, for example with concerns about the patient’s health or wellbeing or in the event of a hospital admission.

However, the service had developed a process for shared care arrangements for attention deficit hyperactivity disorder (ADHD) with primary care and had built effective working relationships with a number of independent and corporate organisations.

We sought feedback from some partner organisations who regularly worked with the service. Their feedback about the staff and the referral process was positive. They described the service as accommodating, responsive and professional.

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

We reviewed the quality improvement plan the leaders shared which outlined the activities taking place. No clear objectives were set for these and no roles or responsibilities assigned. It was unclear how progress was monitored and therefore how these activities contributed to continuous improvement.

The provider did not participate in national audits or benchmarking relevant to the service. Although some learning from incidents was shared with staff in emailed bulletins, we saw no evidence of changes made as a result of such learning. The provider also shared email bulletins with learning from complaints. There were some repeated themes such as record keeping, however due to the lack of systematic audits it was not clear how the provider monitored if any improvement happened.

However, the psychology and therapy team at the service had recently started presenting monthly webinars to psychiatrists on topics related to therapy.