CJP Outreach Services Ltd

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to outstanding. This meant people were protected by a strong and distinctive approach to safeguarding, including positive risk-taking to maximise their control over their lives. People were fully involved, and the provider was open and transparent when things went wrong.

This service scored 91 (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 strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

There was an embedded culture of learning and continuous improvement across the service. The provider demonstrated a proactive and transparent approach to incident management, with robust systems in place to ensure lessons were consistently identified, shared, and acted upon.

A recent safeguarding investigation exemplified this approach. The provider conducted a thorough and objective review, clearly documenting the actions taken to address the issues identified. The investigation reflected an open and honest analysis of what had gone wrong and what could be done differently to prevent recurrence. This demonstrated a strong commitment to accountability and improvement.

The provider maintained a comprehensive overview of incidents, enabling them to identify patterns and trends. This included detailed accident and incident forms that prompted staff to reflect on precipitating factors, the sequence of events, and post-incident outcomes. Where incidents involved behaviours which challenged others, potential triggers were recorded, and a 'lessons learned' section was completed to inform future practice.

Trend analysis was used effectively to understand individual experiences and tailor support. For example, the provider had identified how the lead-up to and aftermath of seizures impacted a person’s behaviour, leading to adjustments in care planning and risk management. This positive response led to staff having an increased understanding of the person’s behaviours and providing the support they needed.

Staff consistently reported receiving constructive feedback following incidents. One staff member told us, “They are dealt with very quickly, the management ask us lots of questions and it’s all very thorough. We get a debrief and the outcomes are shared with us; we have been offered good support.” This reflects an environment where staff feel supported to report and learn from events.

The provider’s use of electronic reporting ensured timely communication and oversight, with managers automatically notified of incidents for review. This streamlined process supported timely analysis and action.

The service’s approach to learning clearly focused on improving outcomes for people. The provider’s commitment to learning and improvement was evident in both oversight and day-to-day practice.

The provider always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

The provider demonstrated commitment to person-centred care from the outset. Following the initial referral, they promptly engaged with the individual and, where appropriate, their family, to get to know the person and carry out a thorough assessment of their needs. Health and social care professionals involved in the person’s care were actively included in the process, ensuring a holistic approach that enabled the provider to plan the right support for the person.

After the assessment, the provider worked collaboratively with the person and their family to agree on a clear timeline for their involvement in recruiting a dedicated support team, placing the person at the heart of decision-making about who they wanted to support them. A member of staff told us how, the staff team recruited for a person new to the service, had completed a 3-month transition period, working with the person’s previous care provider before making the transition to fully take over their care package. This personalised approach to planning, collaborative recruitment, and thoughtful transition ensured continuity of care, fosters strong, trusting relationships, and placed the person at the centre of all decisions from the very beginning.

We saw how the provider had supported a person to move into new accommodation ahead of the full care package starting. They went above and beyond to ensure a smooth transition for the person, by liaising directly with the landlord to ensure necessary adaptations were completed, making the home safe, accessible, and ready for the person’s arrival.

Continuity of care was promoted. For example, when people required a hospital stay, their regular support team, in agreement with the hospital staff, maintained their usual hours, providing familiar faces and consistent support. This approach significantly reduced anxiety and promoted emotional wellbeing during what could otherwise be a distressing time.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

There was a safeguarding policy in place, and this was followed by all staff. The manager was aware of their responsibilities under safeguarding and referrals had been made appropriately. We saw an example of swift and appropriate action being taken where a staff member had failed to follow a person’s risk assessment and put them at risk.

Staff had received training in safeguarding and their understanding and competency in managing safeguarding issues was checked by the provider during supervision. Staff were very clear in their understanding of safeguarding and what they needed to do if they thought someone was at risk.

Raising concerns had been prioritised as a recent policy of the month with all staff encouraged to update themselves on safeguarding policies and procedures and discussions around safeguarding had taken place during the monthly staff meeting.

The provider always worked well with people to fully understand and manage risks by thinking holistically. Staff provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were completed collaboratively with the person, their family and, where appropriate, involved health and social care professionals, ensuring a comprehensive understanding of each persons’ unique risks. Staff used their knowledge of the person’s communication abilities to make sure they had input into the process.

Risks assessments gave detailed information and were scored in relation to the likelihood and potential severity of the risk. Several preventative measures were then identified and the risk scored again with the control measures in place. Following identification of several tailored control measures, risks were re-scored to evaluate the effectiveness of interventions and to determine whether additional safeguards were necessary. This helped enable people to have more freedom or do more as the effectiveness of supportive measures was constantly reassessed.

Each risk assessment was directly linked to corresponding areas within the care plan, providing clear guidance for staff and enabling seamless integration of risk management into everyday care. Assessments were reviewed regularly and updated promptly to reflect any changes in the person’s circumstances or preferences, maintaining a consistently proactive approach to safety.

Potential risks from all aspects of the person’s life were considered. Where activities the person liked to engage in presented possible risks, these were assessed positively and extra measures put in place to enable the person to safely continue to enjoy their chosen activities. These included examples ranging from accessing local facilities to taking holidays abroad.

The provider told us about how lessons could be learned from even the most careful risk assessment process giving an example of an activity staff had supported a person to experience but found that, in practice, the risks were too high, and this would be fully considered and adjustments made for future activities.

A relative told us about the extensive and collaborative risk assessment process which had enabled their family member to engage in an activity they loved despite several serious health risks. They said, “They go the extra mile using incredibly personalised planning, to make sure [person] can access the things [person] loves. For some services, they probably wouldn’t want to manage those risks on a trip, but for [person] it meant everything to be able to go."

The provider was fully aware of all potential risks in the care environment and controlled them well. They had effective systems in place to assess and manage environmental risks within people’s homes. Detailed environmental risk assessmentswere completed for each person and provided clear, practical guidance to staff on how to navigate and reduce any identified hazards. These included considerations of potential hazards to not only the person, but also to staff and visitors to the property.

The provider consistently went beyond their core responsibilities to work in the best interests of the person, by proactively collaborating with landlords and local authorities to ensure people’s homes were safe, accessible, and tailored to their needs.

Prior to the start of one person’s care package, when the person was moving into a new property, members of the provider’s management team worked together with the staff team to create a secure, private outdoor space by clearing the garden, putting up fences and gates. This thoughtful and practical action enabled the person to enjoy their garden safely from the minute they moved in.

By embedding environmental considerations into support plans, the service promoted people’s independence, safety, and dignity, reflecting a truly person-centred and holistic approach to care.

Staffing at the service was exceptionally and uniquely well managed to ensure people received safe, consistent, and person-centred care in their own homes.

Each person using the service had their own team of support staff which the person and, where appropriate, their family were at the centre of recruiting. A relative told us, “The staff are exceptional, the company went the extra mile to make sure the right people were recruited specifically to meet [person’s] needs. The staff shift patterns are matched exactly with [person’s] needs.

Recruitment and induction processes were safe and well managed. Staff followed a robust induction and shadowed more experienced staff until they were confident and had been assessed as competent in their role and the person and their family were happy with them. One relative said, “They shadow shift and as [relatives] we decide when they are ready. CJP come to sign them off.”

Staff followed a training programme which included recognised and recommended training in supporting people with a learning disability and autism. Additional training was sourced in line with the needs of the person staff were supporting. For example, for staff supporting a person with epilepsy, they would have to complete training in administration of each relevant medicine. At the time of the inspection the provider was sourcing training for staff who supported a person with assisted breathing equipment which was being managed by their family and a district nurse. The provider had already sourced a specialist nurse to regularly assess staff competencies following their training.

Members of the senior care team completed the training offered to support staff to make sure of the quality and relevance of the training. Staff were very positive about the training they received. One said, “The induction was very good, very detailed and informative, I feel that we were taught everything we needed to know, honestly, CJP is the best company I’ve ever worked for, and I’ve worked in care for 30 years. If I wanted to do any extra training, I would speak to the manager, she is very accommodating, and I know that this wouldn’t be an issue.”

Relatives told us staff were well trained and exceptionally reliable. One said, “They’re beyond reliable; in [number] of years there has been no staff sick leave in [person’s] staff team. The staff are exceptional; the company went the extra mile to make sure the right people were recruited specifically to meet [person’s] needs."

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider made sure that medicines were managed safely and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff worked with people or, where appropriate, their families to decide where medicines would be stored within their homes. People’s medicines were audited weekly by team leaders and monthly by the case manager or manager to make sure they were stored correctly and that staff were administering them correctly. Errors in relation to medication administration, however minor, were reported appropriately and managed well.