Cookridge 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.At our last assessment we rated this key question requires improvement. At this assessment the rating has remained as 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 ineffective governance in the service.

This service scored 61 (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.Staff confirmed the service had a person-centred culture and the provider’s vision was shared across the team. Staff told us the service was well managed; they said they could go to the manager at any time, and they felt supported in their roles. There were daily meetings to discuss people’s care and staff felt they could openly raise concerns if needed.

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 led with openness and honesty. However, due to the concerns found during the inspection we were not assured that managers always had the knowledge and experience needed to ensure effective care. For example, we found that people did not always have appropriate mental capacity assessments in place, and this had not been identified by the leaders of the service. Due to this we could not be assured that leaders had the appropriate knowledge to ensure people were not unlawfully restricted within the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.Staff told us the registered manager lead with an open-door policy and was approachable. Staff had the opportunity to discuss people’s care within daily meetings and large team meetings were also held to ensure staff could have their say.

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 inclusive and fair culture with equality and equity for staff. All staff were positive about working at Cookridge Court and felt they were treated with respect.

The provider 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.We found that not all areas of the service had effective checks taking place, which meant information about people’s care needs was inaccurate. People’s care plans included information which was inconsistent about their current care needs. People’s risk assessments were not always competed accurately when a risk had been identified. The process for checking daily notes was ineffective in ensuring safe care and increased the risk to someone who, for example, had received the incorrect thickened fluids. Audits were being completed by both the registered manager and the provider. However, these processes were not effective in identifying the concerns found during the inspection. For instance, internal checks failed to detect when people were missing mental capacity assessments. They also did not highlight when staff had not followed the falls procedure. Furthermore, when audits did identify areas for improvement, it was not always clear whether appropriate action had been taken in response. Efforts had been made by the general manager to address some of the concerns during the inspection. However, more time is needed to ensure good practice and knowledge is embedded to ensure a consistently good governance system.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Managers and staff had built a good relationship with local community teams and GPs to help support the service. Appropriate referrals were made to local authorities for support, where needed. Links within the community were continuing to grow with the help of the activities team, they planned to increase peoples access to the community and continued to approach local support groups and schools.

The provider did not always focus on continuous learning, across the organisation and local system. Previous inspection reports evidence that the service has continued to need improvement in the well led domain. Due to this, we cannot be assured that the provider has learned and improved as further concerns have been found at this inspection.However, the provider had made investments into the service to help improve. For example, the service had recently undergone some refurbishment to refresh areas of the environment and give people the opportunity to use other spaces, such as the cinema room and bar for meeting families and friends.