Jaytee Care Demi 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.

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.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 61 (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 told us about the positive culture and vision of the service for the people they supported. This included ensuring the people they supported having a safe and meaningful life which respected their human rights.

We viewed an equality policy, saw staff were equality and diversity trained and staff told us how they promoted people’s human rights by ensuring their individual rights, needs and preferences were documented, understood and promoted by the service.

We viewed staff meeting records which showed leaders discussed standards and goals with the staff team in order to promote collective awareness and understanding. This included discussions about how the service could ensure people’s needs were being met and how staff should perform in order to ensure regulatory and partner compliance.

Staff told us how the culture of the service applied to their roles, including the importance that people were listened to and that care was centred around people.

Leaders did not always demonstrate the skills and knowledge to lead aspects of the service effectively.

At the time of the inspection, the provider and registered manager was not able to be present at the service on a consistent basis, this included the day of the inspection. The provider told us that in their absence a team leader was responsible for leading the service. However, during the inspection, the team leader was unable to share or access some of the information that showed how the service was led in the absence of the registered manager. For example, they were unable to explain what systems were in place to ensure effective oversight of safety and quality at the service. This meant we were not assured that the service was consistently led by experienced and knowledgeable leaders.

The provider and team leader had not identified the concerns we have referenced under the safe section of our report which meant the service was not being managed effectively at the time of the inspection.

However, staff and a relative spoke positively about the provider.

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

We saw there was a culture of speaking-up. The provider told us that staff were aware of the importance of and process for raising concerns, and that this was discussed with staff within team meetings and supervisions.

Team meeting records were viewed which showed that leaders discussed with staff their expectations and what they should do should they ever feel they have concerns about people’s care.

Staff told us they had not needed to raise concerns, but that they were aware of how they should do so and that they were confident the manager would take concerns seriously.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for the people who worked for them.

The provider informed us they valued a diverse workforce which they treated fairly. Staff supported this by telling us they were happy working with the provider and felt they were treated fairly. There were processes in place to consider staff member’s individual needs, such as regular supervisions and team meetings.

Effective governance systems were not in place to ensure safety and quality concerns were identified and acted upon.

Risks at the service had not always been identified and acted upon to promote safety.

For example, we found effective systems were not always in place to ensure: the safe recruitment of staff; the consistent application of principles of the Mental Capacity Act 2005; ‘as required’ medicines guidance being in place; the clear documentation, reporting, review and learning of accidents and incidents; and the identification and mitigation of environmental risks.

This meant governance systems were not effective and exposed people to the risk of harm.

The provider understood their duty to collaborate and work in partnership in order that services could support people.

Staff and the provider were aware of what partners and stakeholders were available to the service and how to access this support. The provider supported people to integrate within the wider community to improve their social, health and emotional outcomes, and we saw that people were supported to access of range of local settings.

The provider did not always focus on continuous learning and improvement across the service.

Leaders did not always have a good awareness and understanding of audit processes and how these could be used to effectively identify concerns and mitigate risks in order to achieve continuous learning and improvement.

As a result, leaders had not identified areas of the service which required improvement, such as those we identified ourselves as evidenced by the issues we identified during our inspection. This meant there were missed opportunities to learn and make improvements to the overall quality and safety of the service.