Cosford House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 63 (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 was developing a proactive learning culture. However, systems to consistently record, investigate and evidence learning from safety events and audits were not yet fully embedded

Some reflective practice was evident, for example a root cause analysis was completed following a fall. Staff and leaders spoke positively about learning from incidents and described using these to drive improvements. However, arrangements for recording, tracking and evidencing this learning were inconsistent. Analysis of falls, accidents and incidents was not yet fully embedded or sustained, and the approach to documenting learning varied. This limited assurance that themes were systematically identified and that resulting actions were consistently followed through. The provider described a “massive turnaround” following changes in the ownership of the service, with the introduction of new digital systems, audits and feedback mechanisms. However, gaps in recording meant that learning was not yet embedded across all safety systems.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People experienced safe and well‑managed pathways into and through the service. Structured assessments and clear management plans were in place to support people with complex risks. Before and following admission, staff worked closely with community mental health teams, Parkinson’s nurses and other professionals to understand risks such as self‑harm, psychosis and physical health conditions. Care plans and risk assessments clearly described how staff were expected to respond and supported people to integrate into the service. Relatives told us they were involved when people moved to Cosford House and when needs changed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. However, oversight of safeguarding documentation and concerns was not effective.

People were supported by staff who understood how to recognise and report abuse and improper treatment. Staff were clear about their safeguarding responsibilities and described feeling confident to escalate concerns. They explained how they would report allegations, including contacting managers or external agencies where required. Examples showed staff challenged professional decisions and advocated for people, such as remaining with a person in hospital to ensure they were not inappropriately treated for dementia.

However, safeguarding oversight did not always clearly evidence referral routes, actions taken or outcomes, which limited assurance that concerns were consistently tracked and reviewed. One staff member told us they would escalate any suspected abuse. They confirmed, “If a member of staff [was] abusing someone then I would speak to management straight away.” This reflected an open safeguarding culture, but this was not yet consistently underpinned by robust and effective documentation.

The provider did not always work well with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were encouraged to take positive risks and to be involved in everyday decisions. However, not all risk assessments and care records were complete or fully aligned with practice. People were supported to go out independently or with staff, attend boxing, exercise and other community activities, and make choices about holidays and social events. Relatives described how staff balanced people’s safety with their independence. One professional told us, “What impresses me is that the residents have the freedom to leave the building and walk into town. That’s freedom and normality, which I applaud.”

However, recording and availability of risk assessments were not always consistent, which meant we could not be assured staff were aware of these, and some high‑risk areas were not fully documented.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service ensured people’s rooms and shared communal spaces were safe.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People were supported by a stable, committed staff team and generally safe staffing levels. Rotas showed planned cover across the day and night, with managers present on site, an on‑call system and activity staff to support community engagement. Both staff and relatives told us there were usually enough staff to meet people’s needs. Staff described thorough recruitment processes, structured buddy inductions, early appraisals and regular supervisions.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Infection prevention and control arrangements were effective and helped to protect people from avoidable infection. Staff ensured communal spaces were clean and hygienic, supported by regular cleaning schedules for people’s rooms, where required, and hand‑hygiene competency checks for staff.

Staff and relatives confirmed that personal protective equipment (PPE) was readily available and used appropriately, and accessible throughout the service. One family member told us, “Yes, they do PPE, and it’s always nice and clean there.” Staff also described having access to personal cleaning cupboards and room‑based supplies, which supported consistent infection control practice.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

People usually received their medicines as prescribed; however, medicines optimisation systems were not yet robust enough to provide full assurance. Inspectors observed staff administering medicines safely, supporting people to self‑administer where appropriate, monitoring pain relief and using body maps for topical medicines. Staff described how they checked that people swallowed medicines and followed up concerns about side effects with GPs and specialists. Relatives were positive about how medicines were managed, including support during home visits.

Despite this, paper medicines administration records (MARs) contained recurring gaps, including missing signatures for scheduled doses and inconsistent recording for ‘as required’ and topical medicines. Some medicines‑related actions within the service improvement plan, including those linked to audits and recording, had not yet been fully implemented. While examples of responsive practice were evident, such as staff addressing unsafe self‑administration, recording was not consistently strong enough to evidence interventions, decision‑making or outcomes. This meant medicines practice was not robust.