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

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

At our previous assessment in October 2025, 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. At this assessment, we found significant improvements had been made. Governance systems and processes had been strengthened and embedded, and the provider was no longer in breach of Regulation 17.

This meant the service was now consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At our previous assessment in October 2025, we found the provider did not demonstrate a clear shared vision, strategy and culture. At this assessment, we found improvements had been made.

Staff knew and understood the service’s vision and values and how they were applied in the work of their team. Staff could explain to us how they were working together to ensure patients who needed treatment could access it.

Since the previous assessment, staff had greater opportunities to contribute to discussions about service development and improvement through regular governance and team meetings. This supported a more open and inclusive culture and provided staff with opportunities to contribute to the future direction of the service

Staff could explain the aims of the service and the provider’s commitment to providing a professional and responsive service to patients. Staff felt able to raise clinical issues with the rest of the team.

At our previous assessment in October 2025, we found leaders did not consistently demonstrate the skills, knowledge and experience needed to safely run the service. At this assessment, we found significant improvements had been made. The provider had strengthened its leadership arrangements through the appointment of an Associate Medical Director and a safeguarding lead, increasing clinical expertise, safeguarding oversight and leadership capacity across the service.

The registered manager had further developed in their role and demonstrated a clear understanding of service performance, quality and risk. Leaders were able to explain the improvements that had been made since the previous assessment, how these were being monitored, and the actions being taken to drive further improvement. This provided assurance that leaders had strengthened oversight of the service and were well equipped to lead it effectively.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff said they were able to speak and raise concerns with senior management. Whistleblowing (Speak Up) training was mandatory. The service had appointed an external Freedom to Speak Up Guardian.

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.

Staff reported that the provider promoted equality and diversity in their day-to-day work.

Staff could apply to work flexibly, for example, flexible working agreements to account for personal circumstances such as caring responsibilities and health issues. Staff could work remotely to attend appointments.

The provider undertook equality monitoring of staff within the service to ensure it is diverse in its make-up and representative of the communities it served. The service did not have equality and diversity champions within the service. The managers said it was something they were thinking of implementing.

At our previous assessment in October 2025, we identified significant concerns regarding governance, oversight and quality assurance arrangements. Leaders had not established effective systems and processes to assess, monitor and improve the quality and safety of the service, resulting in a breach of Regulation 17 (Good Governance). At this assessment, we found significant improvements had been made. The provider had developed and embedded governance systems and processes which supported effective oversight of the service and provided greater assurance regarding the quality and safety of care.

Leaders had strengthened governance arrangements and there was a clear structure of meetings to support oversight and continual improvement. Monthly governance and quality assurance meetings followed a standard agenda and included discussions about incidents, complaints, safeguarding, clinical governance, risks and learning. We reviewed meeting minutes from February to April 2026 and found actions were discussed, monitored and followed up. Psychiatrists also attended monthly clinical governance meetings, complex case discussions and ADHD peer support forums to support shared learning and best practice.

The provider had introduced a comprehensive programme of audits to monitor quality and safety. The Operations Manager maintained a compliance tracker which monitored audit activity, identified when audits were due and supported oversight of actions arising from audit findings. The tracker included audits covering prescribing, safeguarding, health and safety, infection prevention and control, incidents and complaints.

Since the previous assessment, the provider had implemented routine controlled drug and non-controlled drug prescribing audits. These were used to identify prescribing variances, such as non-formulary prescribing or prescribing outside expected durations, and required prescribers to provide a documented rationale and follow-up actions where required.

The provider had also introduced a detailed psychiatrist standards audit. This included a comprehensive review of a random sample of clinical records and assessed areas such as risk assessment, documentation, care planning and communication with GPs. The initial audit completed between October and December 2025 achieved an overall compliance rate of 91%. Where individual clinicians achieved below the provider's required compliance threshold of 75%, additional monthly audits were introduced until improvements were demonstrated.

Leaders had also strengthened oversight of communication with external healthcare providers. Monthly audits monitored GP registration, consent to share information and communication with patients' GPs. Between January and April 2026, compliance rates ranged from 84% to 100%.

The provider had reviewed and updated key policies and procedures, including safeguarding, medicines management, incident reporting and mental capacity policies, to better reflect current legislation and best practice guidance.

At our previous assessment, we identified concerns regarding information governance arrangements and the security of patient information. During this assessment, we found the provider had improved these systems. Prescribers no longer relied on storing prescription images on personal devices. Instead, records were transferred through a secure application directly to the provider's secure systems and this process was supported by a dedicated policy and procedure. This reduced the risk of unauthorised access to patient information and provided greater assurance that confidential information was managed securely.

The provider maintained a risk register which identified operational and clinical risks and documented the actions being taken to mitigate them. This provided leaders with improved oversight of risks affecting the service.

At our previous assessment in October 2025, we identified concerns regarding the provider’s lack of collaboration and partnership working with external services. At this assessment, we found significant improvements had been made. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement.

Managers engaged appropriately with external stakeholders. At the previous inspection, the service had failed to notify CQC and the local authority of safeguarding concerns and other notifiable incidents, including incidents involving the police. During this inspection, we found improvements had been made. Although no safeguarding concerns meeting the threshold for statutory notification had occurred since October 2025, leaders demonstrated a clear understanding of their notification responsibilities and had appropriately notified CQC of relevant incidents, including incidents involving the police.

Systems for monitoring medicines had become more effective through collaboration with the pharmacy. Missing prescriptions were identified through regular audits, with concerns referred to the pharmacy commissioning hub and the police where appropriate. This helped to mitigate risks and strengthened partnership working across agencies.

The provider was strengthening its approach to quality improvement planning and had a framework to support service development.

However, there was limited evidence that formal quality improvement methods had led to completed projects or measurable service changes. Although leaders had identified this as an area for further development, learning, innovation, and continuous improvement were not yet fully embedded across the service.