Cow Lees Care Home

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 requires improvement.

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 good governance at 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.

We found a positive care culture that was being led by the management team through to the care staff delivering people’s care. This was supported by the positive comments we received from people, relatives, staff and external health professionals. One staff member said, “The leadership want staff to get on and work as a team. They want the best for the residents, [people], for them to be safe and looked after well.”

Management told us they were supportive of each other and wanted to improve the experiences for those living across all 3 units of the home. The management team said they valued their staff team and rewarded them for their achievements. The registered manager told us they needed to improve the culture and attitudes at the service when they took over management of the service. Part of the improvements were recognising and rewarding the hard work and staff commitment to driving best practices which they felt they had achieved. The management team were providing support to people, relatives and staff and they had begun to implement and strengthen their quality assurance systems since the last CQC Inspection. Following this assessment we gave feedback to the management team about some of the issues we found and they began to address the issues we raised.

Not all leaders and the provider had the skills, knowledge and experience to lead effectively, or they did not always do so with integrity, openness and honesty.

Relatives were complementary of the management team. A relative said, “I’ve spoken to the manager once. I think this place is well managed.” The provider has not always had effective oversight through leaders, to make sure the management and governance of the service was effective. At this assessment we found some improvements which we have reflected in this report and we have found some positive examples. Since the last inspection there has been a change of registered manager who described to us the challenges they faced at the service when they took over to drive improvement. However, further work was still required to ensure the provider met regulatory requirements and there were no legal breaches of regulation. We saw at this assessment managerial scrutiny had improved however when checks were delegated to others, there remained a lack of scrutiny and oversight.

We found staff felt supported by the manager and deputy manager. All the staff we spoke with told us senior staff/leadership were approachable and emphasised there was a family approach at the home. One staff member said, “It is good working here, I am treated fairly. The approach is teamwork equals dreamwork.” A care staff member shared an example with us showing how sensitively a nurse handled a staff situation meaning confidentiality was preserved. Staff told us managers were visible, approachable and supportive. One staff member told us, “My mentor is the deputy manager. She will come every day and ask about any concerns and every month we will chat personally for some time.” Another staff member commented, “The managers come onto the floor and check a few times a day. They chat with the residents and sometimes join in with the activities."

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

All the staff we spoke with were confident they could, and would, speak up if they were concerned about any aspect of the service. Staff knew who to speak with they wanted to share concerns and were confident they would be listened to. Staff were confident that leaders would not tolerate poor practice. One senior staff member knew about whistleblowing and said, “I would go to management, CQC or the Police. If it was about management, I would go straight to CQC.” Staff felt able and empowered to speak up about any issues and felt confident their views would be listened to. One staff member described an issue they had taken to the managers and explained that it had been managed and resolved sensitively. They told us, “I have been into the office before and spoken to [name of managers] about issues I have had in the past. They are always there to answer your questions.” Another staff member said, “If I have any concerns, I speak to the person I feel I need to."

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.

Staff gave us examples showing how leadership at the home valued their culture and how they supported them to have time off to celebrate religious events which were important to them. One staff member told us, “I am treated fairly here.” A number of staff described a diverse workforce where each staff member was respected. Staff told us they had never experienced discrimination and felt valued for the work they did. Staff told us where a need was identified, reasonable adjustments were implemented to support them to continue to work. One staff member told us there had been flexibility in their working pattern to support their caring duties at home. Other staff gave us examples of changing their work patterns, reducing their contracted hours and developing their skills so they could move into other roles.

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

Since our last inspection, the provider sent to us monthly action plans telling us the improvements they had made to the service and their systems, so they had a good insight into quality at the home. In this report we have reported a number of shortfalls that have an impact on the quality of service which put people at risk. This was because some of the provider audits were ineffective. It was clear some checks were completed but they failed to identify and drive standards in some areas. For example, making sure fire safety checks kept people safe, the environment remained clean and safe and when checks were completed, they were completed by staff who had the right skills and knowledge to understand what was being checked and why. We found regular checks or risk assessments were completed but they were more of a tick box than identifying and driving up standards. The registered manager explained potential reasons why and agreed to make changes to ensure they completed checks of those checks delegated to others so they were confident if any actions were needed.

Staff said changes were positive at the home. One nurse told us, “Since the last inspection the manager is putting in a lot more checks in place and doing more observations. Staff have a lot more training now. This includes Mental Capacity Act, fire, dementia. We will be doing more catheter care and react to red training soon.” A senior staff member told us, “I feel there is a lot more paperwork and the way of doing things has changed. There’s more giving people options and people are showed choices.” One nurse showed us an analysis function on electronic software to check for patterns of behaviours.

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.

The registered manager and deputy manager explained the importance and value of working with other agencies and stakeholders. The deputy manager said they were working towards achieving an accreditation for their dementia care, as well as working with the veteran’s society which meant when requesting assessment for a veteran, they received quicker access to services. Feedback from commissioners showed positive steps to improving practice. The staff team said they worked well together with good communication. Evidenced throughout these findings were that staff advocated for people with other professionals, and staff were clearly confident when seeking advice on health and well-being for those they supported.

The provider 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.

Following our last inspection the provider was required to send to us monthly action plans telling us how they learnt from their own audits, checks and practice. We have reported some shortfalls by the provider in learning from how a quality assurance system supports good outcomes. That said, we found some learning opportunities were taken, for example from other agencies. The registered manager and staff said they learnt from examples of good practice or innovations. For example, one senior staff member told us, “We have different champions. I am the champion for oral care, but we also have a champion for skin integrity and one for moving and handling. Champions get extra training.” This staff member spoke enthusiastically about an external nurse who came in and talked through different types of treatment options people may need and finding out more information about the effects of plaque build-up on people’s heart health. Staff described a culture of learning where they felt confident to own any mistakes to improve their practice. The provider was developing their dementia training programme in collaboration with a leading dementia services development centre.