8 Cosway Court

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.

This is the first assessment for this registered service. This key question has been rated 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 62 (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. The nominated individual told us their goals were to provide personalised and compassionate care in the comfort of people’s homes. They said, “Our team is highly trained, we value promoting independence.”

Not all leaders understood the context in which they 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 staff working at the service were all directors within the company. However, there was no evidence of how the nominated individual assessed the suitability of the other directors within the service. There was no evidence recorded of the manager and other directors’ character, in line with regulations. The nominated individual told us they would address this.

However, leaders were working towards obtaining a Level 5 qualification in health and social care leadership and had backgrounds in health and social care. Leaders had completed a variety of additional training relevant to their role, such as complaints handling and risk management.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There were procedures for staff to report any concerns. There was a whistleblowing policy which listed different ways to raise concerns. One staff member said, “I am aware we have a whistleblowing policy, but I also know I can speak to the manager, or should I not feel comfortable with that, I can ring the CQC direct. Management encourages us to speak up as it helps us improve the service.”

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. There was an equality and human rights policy which listed the protected characteristics. This stated, ‘We will not tolerate any unlawful discrimination’, and ‘Reasonable adjustments will be reviewed on an individual basis.’ No staff raised any concerns about discrimination.

The provider did not have effective governance. Governance systems had not ensured care planning documents were in line with regulations. For example, there was not enough information for staff to manage risks, or support people to meet their nutritional and hydration needs effectively. Some records contained conflicting information, for example information around the support required around medicines for one person was unclear. This put people at risk of receiving unsafe or ineffective care. Additionally, the service did not complete any formal audits. However, there was only one person receiving a regulated activity.

There were policies and procedures which were detailed and regularly reviewed.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. At the time of the inspection, the provider was not working with any other professionals. They told us they had tried to work with other care providers, but this was unsuccessful. However, the service worked well with people and their relatives. For example, one staff member told us how they had successfully worked with a person and their family to achieve a good outcome. They told us, “For instance, a relative of a [person] was concerned about weight loss. We asked them to come for a meeting and went through food charts with them and together we agreed to put a fortified diet plan in place. It’s been really successful.”

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. The manager told us, “We are investing in our staff, everyone is planning to grow.” The manager told us they had started putting together documents to ensure staff could be safely recruited.