Capricorn Cottage

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.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good. This meant the service was 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.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Throughout the inspection there was evidence to show the registered manager and their team worked in an inclusive and compassionate way with people, relatives and staff.

Relatives told us they had access to the managers at the service. One relative said, “Yes, there's two (managers) there’s the deputy manager and the overall manager and we get a chance to talk to them when we visit, I was talking to the deputy manager last night.”

Another relative gave an example of how the registered manager worked in a compassionate way to ensure their family received the right care for them. When asked if the service was well led, they said, “Yes, without a doubt, yes definitely. I mean to put it in perspective, historically [registered manager] actually created the individual unit (at Capricorn cottage) for [Name] because there was nowhere else in the whole of Lincolnshire for them that could meet their needs. So Capricorn Cottage came to [Name’s] rescue basically.”

The people, relatives and staff we spoke with told us, the registered manager and deputy manager had an open door policy and they worked in a supportive way with everyone.

Staff gave positive feedback about the management team. One member of staff said, “Yes, they listen to me. We have an app to communicate with all staff. If manager is on annual leave then another manager replies.” A further member of staff said, “Yes. [Name] is a good manager with any issues. They are so helpful.”

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

The registered manager worked to ensure people, families and staff had the confidence to speak up if they had any concerns about any aspect of the care provided. They had as mentioned in the safe section of this report installed a post box outside their office for anyone to raise concerns to them when they weren’t in the service. People, staff and families could do this anonymously if they wished. The registered manager told us they wanted to know if there were issues as this was the only way they could address them. This statement was reenforced by relatives we spoke with. One set of relatives said, “We've got no issue with talking to any of the management team, not a problem. We haven’t got any fear that they're going to give [Name] notice or whatever, because we've raised an issue. They have pretty much said, we would rather know if you had any concerns or worries.” Another set of relatives said, “We are astute enough to know, where to go and what to do to raise concerns. We know they have got a complaint procedure; we know how to invoke it if we want to.”

Staff we spoke with told us there were regular staff meetings and they were listened to when they raised things. One member of staff also said, “Yeah. I know that there is a good open door policy. Even if having a bad day I can offload and [ Registered Manager] will be able to help with issues. Team leaders are supportive too.”

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.

The service had a diverse workforce and had employed workers from overseas at the service. The provider worked to provide staff and their families with accommodation and give them information about the local area as well as their induction support for their roles. One staff member who had been at the service for over 2 years said, “I had an induction. I am one of the first overseas people to come and work at this care home. I came with my family and they gave an induction for the surrounding living area and a work induction too. They are trying to help.”

Other staff also told us, the support staff received had improved over the last few years. They felt the inductions staff received were more supportive for new starters. One staff member said,

“Yes. (I’ve) been with company 4 years, inductions have improved vastly in the last 4 years. (New staff are) supported heavily for 3 weeks and topped up with HS, etc. They (inductions) are far more intense and better.”

The registered manager told us they worked with individual staff to make sure they felt included in the staff group. They gave examples of how some staff needed more support with training then this was arranged. They also gave examples of how some of their overseas staff had brought in some food on a festival day they usually celebrated in their own country so staff and people could experience this. One member of staff came to seek out the CQC inspector on the day of the visit to tell us how happy they were with the registered manager. They said, “When new staff from overseas have come here [registered manager] has been very supportive of them, they are a good manager.”

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The registered manager used the provider’s quality monitoring processes with good effect. All quality monitoring audits were entered on the company’s electronic system and the registered manager had oversight of the system to ensure where other staff had undertaken audits they could see when actions were needed and when they had been completed. As reported elsewhere in this report we viewed particular audits which supported the safe administration of medicines and ensuring the environment was clean and well maintained. The audits we viewed showed where areas had been highlighted for improvement, actions had been undertaken to address the issues. For example, we noted there had been some gaps in daily temperature monitoring in the kitchen on one of the monthly audits. The registered manager had a meeting with staff about the issues, and the records we saw in the kitchen showed there had been some improvements since then.

There was clear recording and analysis of any incidents so staff could establish if there were any trends and undertake measures to reduce these. We saw when any trends had been established in relation to people’s anxieties or behaviour patterns, people had been referred to the relevant external health professionals and staff followed their guidance to improve outcomes for people.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.