CJP Outreach Services Ltd

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 good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 82 (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.

The management team were clear on what good quality care looked like. They knew about people's needs and preferences, and how to support staff to deliver care to people that was centred around their needs and preferences.

The culture at the service was open and positive. There was a shared vision amongst managers and staff detailed in their ‘Living our Values’ initiative. This initiative concentrated on a core value each month. Managers and staff collectively focussed on a person-centred approach and considered care to be more than just a job. Staff could not name the core values when we asked about them but understood the ethos and culture of the service. One staff member said, “We have a culture of working together, providing the best level of care and treating everyone as an individual.”

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. At the time of the inspection a new manager was in post, but they were not yet registered with CQC.

The manager was skilled and knowledgeable and was fully supported by the provider and members of the higher management team. They had a shared passion for delivering high quality, person-centred care, where people and staff felt valued. Staff enjoyed their job and gave consistently positive feedback about the provider and manager. Comments included, “I think the managers are very knowledgeable and are very experienced.They are always available when we need anything, the managers that take the on-call phone are very good and will always pick up and answer” and “CJP is the best company I have ever worked for and the support they offer the staff is second to none. They offer a counselling service, and they have good support in place for staff that are struggling with their mental health. The managers are also very supportive and make you feel comfortable”.

One relative told us, “I am very impressed with CJP. The manager is person-centred, over and above getting [person] sorted. [Manager] came over with a hedge trimmer and a lawn mower; I can’t praise them enough. They are constantly in touch, even came over for [person’s] birthday”. Another said, “We get phone calls and emails at least once a week. The manager has visited twice and stayed a long time. I appreciate talking about the team.”

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

The culture of the service meant that almost all relatives and staff felt able to speak openly, give feedback and raise concerns. One relative, who was otherwise very complimentary of the service felt their voice was not always heard but felt this was improving with the new manager. Other feedback from relatives included, “Communication is continuous, always available, reliable and full of information,” and “Communication is excellent, I like to be very involved, and they make sure they update me all the time, there are frequent text updates if I’m not there.” A member of staff said, “We have a culture where we can freely speak up and raised any concerns, we may have, we could be listened to, and things would be dealt with in a respectful way.”

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Monitoring and improvement processes were highly effective and deeply embedded within the service. Comprehensive and methodical audits were routinely undertaken, enabling the provider to identify areas for enhancement and implement targeted actions. Their multi-tiered ‘Governance Cycle’ ensured that staff at every level understood their responsibilities and were meaningfully involved in quality assurance activities. Audits of care, support, and outcomes were completed on an individual basis for each person using the service. This highly individualised approach meant that quality outcomes for people using the service were at the centre of the audit process.

The manager maintained full oversight by analysing audit findings to identify emerging themes and trends, enabling proactive and preventative action. The same rigorous auditing approach extended to all aspects of the service, for example, staff development, with detailed audits of training and support ensuring that staff consistently adhered to best practice standards. Oversight by senior management added an additional layer of scrutiny, ensuring the provider had a comprehensive understanding of service performance and quality.

Statutory and regulatory notifications were submitted promptly and appropriately, with safeguarding concerns escalated to relevant professionals without delay. Records of meetings, discussions, performance reviews, and provider engagement were meticulously maintained, all with the clear outcome of driving performance and quality of care provided.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.