Cocoon Harrogate

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 is the first assessment for this service. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of women who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care, which was safe, integrated, person-centred and sustainable, and to reduce inequalities.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The service 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 women and their communities.

The leaders told us how they ensured staff engaged in any changes to the service strategy.

The service values and mission statements were visible across the whole service.

Staff were able to describe the values and mission statement to us and told us how the service used these on a day to day basis to support women and themselves. We observed staff applying the values and mission statement when they cared for women who visited the service.

Staff told us they were proud to work for Cocoon Harrogate and proud of the service they provided to women.

Not all leaders understood the context in which the service delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

The Registered Manager told us she did not have sufficient time to fulfil her leadership duties. However, she had recently started spending one afternoon each month fulfilling these duties. The Registered Manager told us she had received no leadership training.

Staff spoke positively about the service, describing it as a supportive and well-led place to work. They highlighted the responsive leadership with a strong commitment to providing a positive experience for women. Staff told us leaders were visible and approachable for women and staff.

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

The clinic had a Speak Up (Whistleblowing) Policy which encouraged all staff to raise concerns relating to patient safety, quality of care, professional conduct or any other matter which may impact the safe delivery of services. The policy also gave the opportunity for staff to go outside for independent advice.

Leaders told us that, during the previous 12 months, no concerns have been raised through the service Speak Up process and no whistleblowing incidents had been recorded.

Staff told us they were aware of how to raise concerns and said they would be comfortable doing so. They reported leaders were approachable, listened to staff concerns and acted on feedback. Staff were able to provide examples of when they had approached leaders with concerns and how they helped to make improvements, for example when equipment was no longer providing effective scanning pictures.

Following our CQC on-site visit, leaders had undertaken a staff survey which identified staff felt able to speak up when something was not right. Staff had also provided some suggestions for development of the service.

Leaders had committed to undertake a quarterly staff survey going forward, sharing the results at the newly formed governance meetings and using the results as part of induction and culture-setting going forward.

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

Leaders told us their policy was to ensure all people have equal rights with regard to employment and access to the service regardless of disability or neurodiversity. This was reflected in the Disabilities and Learning Disabilities Policy, with Autism and Neurodiversity Statement.

Staff told us they are able to work flexibly within the service to take account of their personal circumstances.

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

The service did not display their CQC registration certificate in a public area. Leaders rectified this immediately, once informed.

Leaders and staff told us there was no formal meeting in place to discuss essential information, such as learning from safety events and complaints. Staff numbers were low and leaders said, there was no opportunity for all staff to be at work together. However, leaders had recognised there was a gap in assurance because of this and they could not evidence all staff were aware of all essential information.

Staff told us they received information through newsletters, team communication and direct discussion with managers.

The service had a Quality Assurance Framework policy in place to establish a robust framework for monitoring, evaluating and continuously improve quality, safety and effectiveness of services. It described regular audits (clinical records, ultrasound reporting, IPC, safeguarding compliance, equipment checks) with findings reviewed and action plans implemented.

Gaps in undertaking relevant audits had been identified as part of our on-site visit. This was a breach of Regulation 17 Good Governance. The service informed us they were producing a new clinical governance framework. The plan was for the clinical lead to review findings from audit to identify any areas for improvement, with actions recorded and monitor through a governance tracker. The service advised future audits would be undertaken at least annually, or sooner where changes in practice or identified risks indicated an earlier review was required.

Staff were aware audits of scans, reports, and cleaning practices were undertaken and had seen evidence of these audits. However, leaders only shared detailed audit findings with staff when audits identified issues or areas for improvement.

The service had a record keeping policy in place which identified confidential information was only accessible to authorised individuals with a legitimate need to know, and that information sharing was appropriate, justified and compliant with legal and professional requirements.

The service identified minimum record retention requirements in line with the NHS Records Management Code of Practice.

The service had a Digital and Systems lead who oversaw the electronic patient managed system and confidential information. The service had a current Data Protection Registration Certificate issued by the Information Commissioner’s Office. A Data Storage Policy had recently been developed as part of strengthening governance arrangements.

The electronic patient record was secure with role-based access controls, two-factor authentication and comprehensive audit trails. A thorough manual checking of future women’s appointments during system migration had ensured continuity of care and helped to avoid disruption to service delivery.

The service had a risk register in place. However, the service had not added any new risks since October 2023. Leaders had recorded review dates; however, they had not identified or documented any new actions, and they had not recorded what they had discussed during the reviews to reduce the risk.

Following the visit leaders told us a new clinical risk register had been developed, with specific attention to the risk of a clinical incident and the mitigations in place (consent policy, chaperone policy, IPC/equipment audits, incident reporting).

We viewed the in date business continuity plan, which only covered temporary short term loss of business and did not reflect longer term loss and subsequent impact on staff, finance or women who used the service.

An external waste management service provision was in place. The building was rented from a landlord with a robust fire safety and evacuation process. A regular maintenance programme was in place. Extinguisher and smoke alarm maintenance was in date and staff had received training in using fire extinguishers.

Leaders were committed to strengthening governance processes by introducing a virtual governance meeting for staff. They told us staff would be able to contribute agenda items and participate in discussions. At each meeting, leaders planned to review key governance, quality, risk, and staffing matters, along with outstanding actions, before setting the next meeting date.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Leaders told us the service worked in collaboration with local maternity units and primary care services to provide a joined up service for women. The service contacted the NHS department directly if a woman required ongoing referral owing to a complication with a scan or blood result.

The service worked with many support services, to ensure women had a better experience of pregnancy such as mental health and talking therapies, yoga, counselling and breathing work.

The senior leadership team were on site and available and approachable every day to meet and talk to women who used the service.

Leaders told us the service was looking to expand their network to include two GP services and, potentially, a national fertility clinic. They explained these partnerships would strengthen referral pathways and governance structures, improve continuity of care, and enhance access to complementary healthcare services for women.

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.

The Registered Manager told us there was limited evidence of how audit findings were escalated, discussed or translated into service improvements.

Staff described examples of service improvements they had been involved in within the service. These included the replacement of an ultrasound machine and adjustments to appointment scheduling, including additional time for report completion and protected breaks. Staff reported leaders listened to their concerns and implemented changes in response to the issues they raised.

Leaders told us how they had improved the way they worked following a complaint, which included increasing times between appointments.

The Registered Manager told us they were not involved in any research currently.