Jane 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

We identified two breaches of the legal regulations. Governance processes and audit were not effective to ensure information within people’s care records was correct and guided safe practice. Management oversight was not effective to ensure people were treated with dignity and respect at all times. The company values were not widely known by staff and the behaviours of some staff did not show integrity or respect. However, we also observed staff who did demonstrate integrity and respect for people. Staff felt supported by the registered manager and provider and enjoyed working at Jane House. There was partnership working with families, professionals, and other organisations.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were inconsistencies in the culture of the service. Some staff did not show regard or respect for working within people’s homes. There was an absence of honesty or integrity from these staff when we spoke with them about their actions. Staff were unable to tell us what the core values of the service were. A senior member of staff told us “I think they are something written down on a piece of paper when you start.” Other aspects of the service culture were positive. Staff were open and friendly. We saw staff were respectful of people and person-centred practices. Staff were approachable and keen to talk about their work. Staff told us, “We are like a big family, I love my job.”

There was a lack of understanding or information about the values of the service. There was no evidence of values being displayed or discussed. We asked staff, including senior staff, for a copy of the company values. These were not made available to us because staff did not know where to find them. The values of the organisation are displayed on the providers website. This was not known by staff we spoke with. Values, behaviours, and codes of conduct were listed on staff induction checklists and signed by managers as completed.

Staff were supportive of the registered manager. Some staff said the service would benefit from having the registered manager working on site more often. This would ensure a consistent management approach and oversight. Staff thought the registered manager was knowledgeable, personable and a good leader who put people at the heart of the of the service. They felt valued and listened to by the registered manager. We saw positive interactions and engagement between people, the registered manager, and senior staff. It was clear people felt relaxed in their company and were used to spending time with them. The senior team knew people and their needs well.

There was a clear organisational structure. The registered manager relied on senior staff for the day-to-day management oversight of the service. During the assessment, some senior staff did not show a clear understanding of their roles, responsibilities, and contributions to ensuring a person-centred service. We saw some staff did not show the same level of respect for senior staff leadership as they did when the registered manager was in the service. We made the registered manager aware of our observations. Polices were in place to support management processes.

Staff knew what processes supported them to raise concerns within their organisation and with partners agencies. Staff told us they felt “Listened to and empowered to make suggestions.” Staff told us they always felt able to speak to any of the management team. Staff took part in individual and group supervision sessions. Staff told us, “Supervisions are helpful,” and they, “Can raise anything.”

Processes were in place to enable staff the opportunity to speak up. There were regular staff meetings, supervision sessions and appraisal. These included open and honest feedback which led to improvements in care. Staff knew how to raise concerns to CQC and other organisations.

Staff uniqueness, diversity and ethnicity were embraced within the team. Staff told us their individuality was supported by the organisation and they were treated fairly. Staff working on UK health and care worker visas told us they had good employment conditions and enjoyed working in the service. Comments included, “What’s not to like, it’s such a fun place to be.” Staff told us the shift pattern and the number of hours they worked suited them. One staff member said, “I am happy with it. It suits me.” Staff told us they had regular breaks and separate staff facilities were provided.

The provider welcomed diversity in the workplace. Policies and procedures supported this. Relevant legislation and best practice guidance was implemented to ensure staff were treated in a fair and equitable manner. Recruitment processes supported fair employment opportunities. The provider was registered as a UK sponsor for overseas workers and understood their responsibilities within this.

We were not assured the leadership and oversight of the service was effective. The registered manager told us they visited the service three days a week. Outside of this time they worked from the providers head office in Cambridgeshire. We visited the service on three occasions including when the registered manager was on annual leave. Senior staff in charge of the service did not identify staff practices seen by CQC inspectors. These included staff members using people’s personal living accommodation for their own purposes. There was also a failure to identify or provide an honest account as to why some care records were not accurate. Staff told us there was a ‘more relaxed’ style of management when the registered manager was not present. Senior staff told us they could always get hold of the registered manager, and they spoke daily to provided updates on the service.

The provider's processes for quality assurance and audit were not robustly applied. Quality assurance checks had failed to identify inconsistencies in information recorded in people’s care records including risk management and behaviour support plans. This meant that some information could not be relied upon as being accurate or up to date.

People used community services and facilities and participated in ordinary sessions. People had access to local health facilities and professionals for medical treatment.

The registered manager and staff worked in partnership with other professionals and community groups. They attended provider forums and registered manager network groups. Information was shared through team meetings. Staff told us they were proud of the relationships they had with people’s families and health care professionals. They told us communication was good and they worked in partnership with each other.

Feedback received informed us the service worked in partnership with health and social care professionals. For example, working with deprivation of liberty assessors when applications were made to deprive a person of their liberty.

The service worked in partnership with other agencies. These included healthcare services as well as local community resources. Records showed that staff had contacted a range of health and social care professionals. This enabled people’s health and wellbeing needs to be assessed so they received the appropriate support to meet their continued needs.

The registered manager promoted a culture of learning from mistakes. They understood their responsibility to be open in the event of anything going wrong. They shared feedback with people and staff to ensure lessons were learnt. This included shared learning from CQC assessment outcomes in the providers other services. Staff told us they enjoyed working for the provider and, “Seeing money spent on improvement,” Another staff said, “It’s good to see money put back into the service.”

The registered manager showed us a presentation about ‘capable environments’ which they had been asked to present at a provider forum hosted by a local authority. This showed how they had adapted the buildings and environment at Jane House to improve people’s quality of life and outcomes. There were stakeholder surveys and keyworker meetings which provided an opportunity to provide feedback to the provider about the service and peoples experiences. These were used to drive service improvements.