Cottingham Manor 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. This is the first assessment for this service. This key question has been rated 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.

This service scored 62 (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.

The vision and values of the service were prominently displayed. The registered manager was able to describe their strategy and ambitions for the service and understood the challenges. Policies thoroughly supported these aims. The provider undertook regular quarterly visits to support staff and the service. A staff member told us, “We can talk to anyone and be transparent if you need any help.”

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.

Staff were actively supported to develop. Many staff members had been promoted either within the service or within the wider provider group. The registered manager and senior staff were visible within the service and occasionally worked shifts alongside staff. However, feedback from staff about the management of the service was mixed. Comments included, “The registered manager is very approachable and very fair. [Senior staff member] is really helpful and supportive. It’s spot on”, “All managers are quite approachable and listen”, “Seniors are great. Don’t always get support from the management team. Both seniors are brilliant” and “[I] feel supported by my senior.”

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

The service had a variety of mechanisms in place for staff to speak up and improve the service. Staff were encouraged to raise concerns and were confident their voices would be heard. When asked staff comments included, “Whistleblowing ensures staff can have a say and feel listened to without being judged”, “We can make a complaint and you don’t have to put your name down”, “You can go and report anything you’ve seen; it’s a safe procedure” and “At one point there was a big divide between days and nights. Raised concerns and now it’s more person-centred.”

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 were treated fairly and equitably. Policies were in place to support this. A staff member told us, “Yes, anyone can go speak with managers.” Another confirmed, “Yes, staff are treated fairly and equitably.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always use systems effectively to manage and deliver good quality care and support. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The governance systems used by managers had failed to identify the concerns found during this inspection. Regular audits took place. However, they had failed to identify the concerns found during this inspection or those concerns raised by people during the residents’ meeting, for example. The registered manager or the deputies undertook a daily walk around the service. However, these had not identified the observations made during the inspection of the feedback received from people. Policies were reviewed regularly.

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 were open and transparent. Effective collaboration took place with all relevant stakeholders to support positive experiences for people. The registered manager described recent work with dementia services.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering outcomes and quality of life for people. However, there was a lack of focus on people’s day to day care.

The provider had a robust strategy in place, which was reviewed annually. Each year a new initiative focused on improving care for people was launched, implemented and met. This provided a focus for everyone to support people to achieve their goals and ambitions. However, some aspects of the service had not always been identified as requiring improvement. This meant people’s day-to-day experiences were not always appropriate.