Jah Jireh Maryport

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 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 service was in breach of legal regulation in relation to governance at the service.

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 and strategy which was based on transparency and engagement. They did not always understand the challenges and the needs of people and their communities.

We found a lack of provider oversight of audits, meetings, sharing feedback and learning outcomes. There was a need for strengthening the systems that are in place. For example, the Quality Assurance and Audit Policy outlined the frequency of monitoring action plans, meetings and feedback. However, we found no evidence of these occurring.

We found the provider had not always maintained sufficient oversight of the conditions of their registration in relation to the needs of people they were authorised to support. This resulted in people with complex needs being admitted to the service, despite it not being registered or specialised to meet those needs.

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.

The provider was supported by a deputy manager.

Staff told us they felt supported by the current management team and felt listened to when they raised issues. A staff member told us, “There is always someone available. They are very approachable, I feel respected.”

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

Staff told us they were aware of the service’s whistleblowing policy and procedures, although they had not needed to use them.

People using the service and their relatives told us they were unaware of any meetings where they could share their views or how they could provide feedback. However, we did see a feedback survey form available for people and visitors in the entrance area of the home.

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.

Staff were mainly employed from the local area. Some staff were from overseas and were recruited as part of a sponsorship scheme through the provider.

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.

The home did not submit all the required notifications to us, which is their legal responsibility to do so. In discussion with the provider, they stated this would be addressed.

We found evidence there was a lack of visibility by the manager within the home with 1 person telling us, “I didn’t recognise the manager when she brought the doctor this week, that's how often I see her.”

Although some audits were in place, they had not identified or addressed the concerns we found during the assessment, for example, fire evacuation plans.

We found evidence that risk assessments were not always completed for people, which could affect their safety and quality of care.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

We found evidence that information was not always shared with other people, which would allow for strengthening procedures around for example reporting safeguarding incidents to the local authority.

We found evidence of good partnership working with the local GP who visited weekly. The GP told us they had a good working relationship with the staff.

We found evidence of referrals being made to the local CHESS (Care Home Education Support Service) and district nursing service.

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.

We found there were no clear systems in place to regularly audit and monitor the provision of service or outcomes for people. The involvement of staff, people and their relatives required strengthening in the development of the service and in making improvements.