JS Care 4 All 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. This is the first inspection for this service. This key question has been rated requires improvement. This meant the provider 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 in breach of legal regulation in relation to good governance.

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, and engagement. They did not always understand the challenges and the needs of people and their communities. Systems and processes were not always in place to give the provider a clear direction. This meant the provider did not always set clear outcomes, which contributed to the shortfalls we found during this inspection. Staff told us they worked as a team and supported each other; however, we found there was limited overall direction from the registered manager to drive improvement. We discussed this with the registered manager who understood the need to set a clearer direction to help improve safety, quality and service overall.

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. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. The registered manager was experienced, and passionate about their role. However, they had not established robust governance and quality systems to identify issues found during the inspection. The registered manager told us they were responsible for the care plans and risk assessments, which were lacking in detail, not person-centred, and did not always provide clear guidance for staff on what to do if risk occurred. During the inspection, they explained the actions they would take to reduce risks and improve the provider going forward. The registered manager knew people well and was committed in ensuring people received safe care. This was done through seeking feedback from people, relatives and staff, as well as carrying out spot checks. A relative told us, “The registered manager is excellent. When they visited us here face to face, they’re really go the extra mile. Their heart is in it." Staff were also positive about the registered manager. A staff member told us, “[Registered manager] is approachable, supportive, and professional. I feel comfortable raising concerns or asking for guidance, and I know that any issues will be taken seriously.’’

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.People and their relatives were encouraged to share their views about the provider through surveys, which the registered manager actively used to seek feedback. Staff said they felt confident to raise concerns and were aware of external services available to support them in speaking up when needed. They felt assured that any concerns raised would be taken seriously and addressed without delay, creating a culture of openness.

The provider valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff told us they felt valued, and their individual circumstances were recognised and supported by the registered manager. We received examples where staff needs, such as family commitments and work-life balance, were taken into account. Policies and procedures reinforced the provider’s commitment to equality, diversity, and inclusion.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Governance systems were not in place or were not working effectively to provide the oversight of the provider. As a result, the provider had not identified the shortfalls found during this inspection. There were no formal audits or monitoring systems in place to assess the quality and safety of the provider. For example, there was no oversight of accidents and incidents to identify potential themes and trends and prevent a recurrence. There was no effective auditing of medicines to identify errors or shortfalls, meaning opportunities to drive improvement and prevent recurrence were missed. PRN (as required) medication protocols were not in place at the time of inspection. Recruitment processes were not consistently robust, as evidence explaining gaps in employment history had not always been obtained. There was no end-of-life care planning in place, and the provider had not explored, documented, or reviewed peoples’ preferences in relation to end-of-life care. Care and support plans were in place; however, these contained errors, including incomplete sentences, which reduced their clarity and overall quality. Consent records were not consistently signed by the relevant person. Due to the lack of auditing and oversight, the provider could not ensure that records were always accurate or complete. This meant the provider could not always be sure that people were receiving safe and appropriate care.

The provider understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement. The provider shared information and worked with a range of professionals and services to support people in their own homes. We received positive feedback from external professionals who worked alongside the provider. One external professional said, “JS Care for All are very responsive to any requests from us and will often go over and above to ensure a person has support in place at short notice, which is something we value and the people value.’’ We were told the working relationships were strong.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. 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 processes and systems were not in place. There was no effective system for monitoring, analysing, or identifying themes and trends relating to accidents and incidents. This meant potential risks to people could not always identified and lessons were not consistently learned to prevent reoccurrence. As a result, opportunities to drive improvements within the provider had been missed. Following our feedback, the registered manager developed an action plan to address the areas of concerns we identified during the inspection. The lack of quality assurance systems meant the provider could not always identify or address shortfalls in a timely way, which limited its ability to demonstrate a culture of continuous improvement. The provider sought feedback from staff through surveys, supervisions and team meetings.