Cordelia 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 inadequate. 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. The provider was previously in breach of legal regulation in relation to governance of the service. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

This service scored 71 (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. Improvements were found at this assessment; the management team supported an open culture and had created a strong team ethos. Staff spoke positively about working at the service and felt well supported in their roles. One staff member told us, “The manager is 100% supportive, all the management are helpful,” another said, “We all work well together. We have built up a good team. No one leaves things. If you see it needs doing, you do it. Everyone has the same approach, and I think that because that is how the manager is”. Processes to involve people and staff in developing the culture included seeking people's feedback, through meetings and questionnaires on the quality of care and service provided. Where suggestions were made, action was taken.

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. People and relatives knew who the management team were, and how to contact them. Comments included, “The manager is approachable, all the staff are,” and “The managers are good and often around.” Staff understood their roles and responsibilities and told us they felt valued and supported by the management team. One staff member said, “From the bottom of my heart, I couldn’t ask for a better manager,” another told us, “Our manager is really very good, they always have a smile on their face. They make you feel relaxed, if you get something not right, they will tell you and explain so you understand and get it right the next time."

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff felt confident to raise any issues or concerns with the management team if needed. One staff member told us, “If there was any worry our manager or deputy would act on it straight away. They would or we could even contact the police, or you (CQC) if this was needed.” The provider also held regular team meetings, where staff had the opportunity to raise concerns and offer suggestions. The registered manager understood the need to be open and honest when things went wrong in line with the responsibilities under the duty of candour.

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 told us they felt included in decisions about the service and enjoyed working for the provider. All staff had received equality and diversity training. The provider’s policies promoted equality and diversity, and a diverse staff team has been recruited to support people living at the service.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. At our last inspection the provider had failed to operate robust governance systems. Improvements were found at this assessment and the service was no longer in breach of this regulation. Managerial oversight and governance of the service had improved since the last inspection and a range of systems and processes were in place to monitor the quality and safety of the service. However, we identified an environmental risk had not been reported in a timely manner to mitigate the risk of a fire door not closing properly. Also, some control measures to mitigate the risk were not always followed by staff. For example, the door to the hairdressing salon being left unlocked, which contained hazardous hair products. Despite these shortfalls, which were addressed during our visit, the management team demonstrated a commitment to ensure the improvements made were sustained to ensure people consistently received safe care and achieved good outcomes. The registered manager told us, “Knowing each person is well cared for, feels safe and has all their needs met, is what it is about for me”. The registered manager demonstrated an understanding of the regulations and their responsibilities. For example, they had informed us about important events within the service.

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. Staff worked in partnership with health and social care professionals to ensure people had the best outcomes for their health and wellbeing. This was confirmed by people and relatives. The management team had been working closely with the local authority quality teams to make the necessary improvements to ensure the quality and safety of the service were made. Feedback shared was the service had completed all actions and had made significant progress, which was evident during this assessment.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. Improvements had been made since the last inspection for example in care records and the values and culture of the staff team which demonstrated lessons had been learnt. Staff felt supported by the provider and spoke about the opportunities available for their personal development. One staff member told us, “My induction was first class. I had time to learn about the residents and to complete my training, the manager and deputy were always there if I wanted to ask a question. The other staff were really helpful too.” Another said, “My training was excellent. I learnt things I never knew even though I have worked in care before”. Staff recorded incidents and accidents, and these were reviewed by the management team and action taken to prevent reoccurrence. Any lessons learnt were discussed in team meetings.