Cosford House

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 changed to 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 68 (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.

There was a clear and positive shared culture, and people, staff and relatives consistently experienced Cosford House as a warm, family‑orientated home. The provider described being “so passionate” about the service and focused on “the quality of the care” and people’s quality of life. Staff, relatives and professionals consistently reflected this ethos in their feedback describing it as homely, safe and welcoming. One professional explained, “Cosford House is a business, yes, but not an institution. It’s home to its residents. Firstly, Cosford House is owned and run by a family and it shows.” Managers were visible and hands‑on in day‑to‑day care, and staff and people spoke about long‑standing relationships and “their own little family there”.

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.

Leaders were visible, hands‑on and highly regarded by people, relatives, staff and professionals, although some governance processes had not yet fully caught up with the pace of operational improvement. Staff described them as approachable and supportive, giving examples of flexible rota adjustments for caring responsibilities and health needs, and practical support such as equipment to reduce strain at work. Relatives reported strong, trusting relationships with the provider. One told us, “[The registered manager] always rings to talk about any changes, and talks it through, checks with me and importantly with [Name] as well.”

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

The culture supported staff to raise concerns and speak up, and there was evidence that managers listened and took action. However, recording of how learning was captured was still developing. Staff told us they would report concerns directly to the managers. They described staff meetings as group discussions where their views were sought rather than managers “telling us what to do”. The provider had introduced structured handovers, incident logs, safeguarding logs and staff meetings focused on supporting more open discussion of practice and concerns.

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.

Leaders promoted an open, welcoming culture where staff felt accepted as individuals and were supported to balance work, health and family responsibilities. Staff described the atmosphere as “very friendly, welcoming, not judgemental”, and said there were “no issues with staff members” and that people worked well together as a team. While there was less explicit documentation about workforce equality data and formal diversity monitoring, the feedback from staff and relatives, and the way reasonable adjustments were made in practice, supported this score.

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.

Governance systems were developing, and leaders had introduced audits, digital care systems and a detailed service improvement plan. Day‑to‑day operational leadership was evident; however, governance arrangements were not yet effective or embedded. At the time of inspection, only a small number of service improvement plan actions had been completed, with many still in progress or not started, and care plan audits were only just being implemented.

Training records showed high levels of mandatory training recorded as incomplete, and care records for several people contained gaps, including incomplete risk assessments, consent documentation and medicines records. Safeguarding and incident documentation did not always clearly evidence referral routes, actions taken or outcomes. Although leaders recognised these weaknesses and were taking steps to strengthen oversight, including moving to digital systems and using external support, governance processes were not yet reliable enough to provide assurance that management and oversight were consistently effective or sustainable.

The service had strong links with the local community and partner organisations, which supported positive outcomes and enriched people’s lives. People accessed a wide range of community activities and people were also involved in community open days, where they shared their artwork and woodwork with the public.

There were established partnerships with health and social care professionals. External professionals and emergency services gave very positive feedback; an ambulance crew described the service as a “fantastic place,” adding that staff were “very caring and professional”.

The service also worked closely with a local theatre, which commissioned a person’s artwork and offered regular visits. Plans were in place for a free film night chosen by people. One professional said, “[People] always seem content and happy”, and described Cosford House as “an effective and much needed service” for the local community.

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.

Learning and improvement were not yet fully embedded, and leaders did not have effective systems to ensure improvements were consistently implemented or sustained. Although the service had introduced audits, digital care systems and a service improvement plan, many actions remained incomplete or had not yet started. This meant that important improvements were not always in place.

Leaders had introduced digital records, structured audits and improved incident review in the last 18 months. There were some examples of learning from events, such as a root cause analysis following a fall, which led to changes in handover processes and training plans. However, the high number of outstanding actions on the service improvement plan, alongside incomplete care plans and risk assessments and recently introduced medicines and training audits, showed that learning, improvement and innovation were not yet embedded or sustained across the service.