Jaden 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 inadequate. At this assessment the rating has changed to 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 provider was previously in breach of the legal regulation in relation to good governance. Sufficient improvements were not found at this assessment, and the provider remained in breach of this regulation.

This service scored 57 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion. The provider’s statement of purpose set out the aims and objectives for the service. It stated that the service was ‘an independent unique specialist transition service’ and that they ‘provide short term accommodation for adults with special needs.’ The staff were aware of the vision of the service.

However, systems in place did not always support this. For example, one person was receiving regular short stay respite each month. There was no information as to how this, or the care they received, was part of long-term planning for the person. People’s support plans did not promote independent living skills such as budgeting as people’s food was bought for them out of a service budget. There was limited information regarding people’s longer-term goals.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. The nominated individual and registered manager were both involved in the running of the service. The registered manager was not actively involved in some aspects of the service and was not able to explain why some processes were in place. For example, why some restrictions such as the internal CCTV monitoring, locking of the laundry room, locking away of some kitchen items was in place stating, “It’s just as it’s always been, I inherited it”.

The management team did not always have the knowledge or understanding to ensure the service provided safe and effective care in line with best practice guidance. For example, there were shortfalls around best practice in relation to assessing risk, restrictive practices and people’s mental capacity. However, feedback from a family member was very positive about the registered manager and their ability to provide competent staff and manage the service.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff and family members told us they could speak out and felt that they were listened to. The provider had policies in place to enable staff to speak up such as their whistleblowing policy.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. The providers procedures had ensured that incidents had been recorded. One incident report did not contain sufficient information to identify the events that occurred. This was highlighted to the manager who was responsive to the feedback.

There had been few accidents, action had been taken where these had occurred. Families said they could raise concerns, and that they will be listened to. People could raise concerns including externally. Staff felt they could raise concerns, and they would be listened to.

The service 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. We identified a number of shortfalls at this inspection, which included processes for safeguarding, managing risk, staff training and supervision, medicines, monitoring and improving outcomes, consent to care, mental capacity and restrictive practices.

There was no continuous improvement plan, and we were not assured the provider always operated effective governance systems to process, identify, monitor and drive improvement across the service. The registered manager did not have oversight regarding important service delivery including funding and quality audits.

The registered manager understood the health and care needs of people and how to access external health and social professionals if required. The consistent staff team helped ensure people received continuity of care. People were largely independent in accessing the community and so there was limited involvement from the staff team into the local community. However, the service had built relationships with local Transport Police to support a person.

The provider did not always focus on continuous learning, innovation and improvement across the organisation. 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.

Quality assurance systems needed further implementation and development to ensure they were effective in identifying areas for improvement. Where external professionals had undertaken quality monitoring of the service in 2023, some actions identified as being required had not been completed. Internal audits had not identified the areas for the improvement we found during this inspection.