Jubilee 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 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 75 (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. A concise missions and values statement supported the providers vision providing clear expectation for everyone coming into contact with the service, with clear reference for people living at the home. The shared direction and culture was lived and supported from provider level down, with clear evidence that people were at the centre of the service. This was supported further with recorded care plans ensuring any required individual adjustments were recognised and implemented to ensure the service was responsive to their individual needs and preferences. Systems and processes were reviewed to ensure they remained effective to improve outcomes for people.

The provider had inclusive leaders at all levels who understood the context in which theydelivered care, treatment and support and embodied the culture and values of their workforceand organisation. Leaders had the skills, knowledge, experience, and credibility to leadeffectively. They did so with integrity, openness, and honesty.The service required a manager to be registered with the CQC. A manager was in post and hadstarted this application process. The management team were visible and accessible during ourinspection. We saw people and relatives held informal conversations discussing routine dailyevents and activities. Staff spoke highly of the new manager; they told us they felt listened toand that communication in general was good. Staff comments included, “We have had a lot ofmanagement changes, not always for the best but with the new manager in place it feels like theservice is settling down with more focus on people and improving the environment foreveryone.” A relative said, “Communication was previously difficult, I know the new managerfrom a previous service, she’s much better to communicate with and always makes time to beavailable.” The manager told us they were always available for a chat and happily took feedbackof any kind with a view to improving the service provided.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People told us they would not hesitate to raise any concerns or complaints. A complaints policy was available for guidance of what to expect and information was promoted in a range of formats for people. Where complaints had been raised a log was held which included details of any resulting actions. The information was reviewed to target any emerging themes, and oversight was completed at provider level. This helped to foster an open and transparent service which welcomed all feedback to support improvement.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider held regular meetings with staff who understood the need to treat people and each other as individuals with respect and inclusion. A clear equality, diversity and inclusion policy was updated and amended as needed which provided support to the sponsorship of individuals from overseas with varying backgrounds. Staff and people spent time getting to know each other and learning about diverse cultures, forming professional working relationships, and understanding.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment, and support.They acted on the best information about risk, performance, and outcomes, and shared this securely with others when appropriate. The provider had effective governance arrangements which included clear accountability, risk management, and performance monitoring. A range of audits and checks were completed to check service performance. This included routinely collecting and analysing data on service delivery, quality, and outcomes to show areas for improvement and assuring the quality and safety of the service provided. Robust policies and procedures were in place and updated for information security and data management. Electronic record keeping helped the sharing of between different healthcare providers to improve consistency of care and the experience for people using services and helped with sustainability by preventing duplication.

The provider understood the benefits of local collaboration, working with partner organisations to underpin, and support the shared values expected by people receiving a service. The managertold us, “Collaboration, support, advice, and working together strengthens Jubilee House’s ability to support people with more complex health and social care needs.” Electronic care plans enhanced the sharing of information, enabling effective evaluation with actions to address emerging risk, reducing duplication and improving outcomes Examples of clear communication and a shared understanding of goals and values was provided during the assessment process. One health professional told us, “There is a clear focus on the health and well-being of people, recent changes have led to improved communication and escalation of risks which have led to improved outcomes in particular for people’s health and wellbeing. Our weekly visits help reduce unnecessary referrals for appointments at both the GP and hospitals which also helps to reduce their waiting lists and workloads.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. They actively contributed to safe, effective practice and research. People their relatives and staff told us they felt part of the service and their input, including feedback of any kind was valued by the provider. A relative said, “Any concerns I share are acted on, I get updates, and I feel involved in [relatives] daily care.” A staff member told us, “We have routine opportunities to provide feedback for example, during daily shift handovers, throughout the day we can access the manager, we collaborate with health visitors, we also have staff meetings and support resident and relative meetings. People fill in questionnaires and we ask them daily how they are getting on, if everything is okay…” People told us they had been involved in the new decoration colours used across the home including the dining room area. The provider had recently transferred paper record keeping to electronic systems. Reviews found some difficulties usings separate systems for example to record care and to manage people’s medicines. This was under review to further streamline processes and improve outcomes for people. For example, where new or emerging risks were found, actions were taken to collaborate with people to manage those risks, removing potential barriers to care and support whilst promoting independence. Provider oversight of systems and processes ensured where risks and/or improvement was identified as part of ongoing reviews that outcomes were used and reflected across partner services. Other examples of partnership working which helped to improve people’s experiences included, collaborating with the local authority, which was identified as major partner including commissioning and contracting of services. The manager also told us about collaborative working with dementia forward across the provider group of services along with group led presentations promoting best practice, new guidance, lessons learned and exampled a resulting new initiative with implementation of mental health hubs. Dementia Forward is a local charity supporting people living with dementia and their families. The manager told us how they were an early adopter of ‘Immedicare’ providing care homes with 24/7 ‘virtual frailty ward’ support via video call from a very experienced and supportive team following a pilot in York. Immedicare is an NHS digital health service, working with York Virtual frailty ward for advice and support.