Jewel Home Care

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 newly registered service. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

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

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

There was a lack of shared direction and cohesive culture across the service. The service did not have a visible strong direction and culture that was shared between staff and leaders. There was little evidence of effective leadership guiding day-to-day practice. This absence of a clear, shared vision contributed to inconsistent standards of care, and a lack of accountability. Without a strong and inclusive culture, staff were not supported to deliver high-quality, person-centred care, and this placed people at increased risk of receiving care that did not meet their individual needs or uphold their dignity.

Reviews of people’s care plans did not demonstrate a fully inclusive and collaborative process when developing their care plan.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Significant concerns with the leadership and governance of the service were identified throughout the inspection. The registered manager was unable to identify the precise number of staff employed, and the names on the list changed throughout the inspection.

We requested the staff training matrix, however the staff names on the matrix did not match the list of staff employees we had already been given by the provider. We shared our concerns with the provider and requested an accurate training matrix, however, the second matrix submitted by the provider still did not match the names of the employed staff. This meant the provider could not demonstrate they had oversight of staff training and competency.

Throughout the inspection, the registered manager had to regularly defer to the care coordinators or the deputy manager for clarification in order to answer our questions about the needs of people the service was supporting.

People did not feel they could speak up and that their voice would be heard.

During the inspection, we received a large number of concerns about documents not being correct, management oversight, and the treatment of staff.

This meant staff did not feel safe to raise concerns with the provider. This impacted staff from sharing concerns, fostering a potential for a closed culture.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There was inconsistent evidence of team meetings and supervisions to show staff were included in decision making and improvements were required to ensure equity in how staff across the service working in the service were viewed and treated.

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 provider had failed to operate effective governance systems. The provider had not identified any of the issues we found during the assessment.This had placed people at an increased level of risk. Audits and oversight had not been effective at identifying the shortfalls in the service.

There was a disconnect between information leaders were providing to us during the inspection, what was recorded on official documentation, and how people were actually receiving their care and support.

We were advised by leaders that a staff member had been dismissed for safeguarding concerns, however, identified through rotas this was not the case and the staff member had still been delivering care to vulnerable people, and was still scheduled to deliver care in upcoming rotas. The registered manager was unable to clearly explain how this error had occurred.

We identified a significant lack of safeguarding within the provider’s digital logging in and out system. Staff should only be able to log into a care visit once they arrive at the person’s home to commence the delivery of care, however, at the time of this inspection, staff were able to log into a person’s care visit from anywhere in the country. This was only identified by inspectors upon checking the GPS (Global Positioning System) data for the call monitoring system. This meant the provider had no oversight in respect of whether people had received their care calls, and left those who lived on their own, at increased risk of neglect by staff not attending their care visits, but recording on the system that they had attended.

We could not be assured the provider’s training records were accurate and reflective of training staff had completed, and there was a lack of competency assessments for staff.

During the inspection, we also observed a significant number of documents and records being created, amended or reviewed on the provider’s digital system whilst inspectors were in another room. This meant the provider could not demonstrate all of their records were in place, and accurate prior to our inspection.

As a result of the significant concerns identified at this inspection, we gave the provider an opportunity to make immediate improvements. However, the provider’s response did not assure us they understood the severity and magnitude of the concerns and could not demonstrate concerns would be rectified in a timely manner, therefore, we took further enforcement action.

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.

The provider had not always built relationships with health and social care partners. There was limited evidence provided to show that the service was collaborating with partners to improve the service.

We did see evidence for 1 person where the provider had communicated with the person’s relative and the GP regarding a decline in their health and mobility.

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.

The provider did not have effective oversight of how care was delivered. This meant opportunities to analyse and review accidents and incidents for themes and trends were missed. Learning was therefore not identified or shared with staff. This meant improvements to the service and the care people received were not always considered or put into place.

Following the inspection, the provider submitted an action plan detailing the areas which they had immediately focused on improving, and areas which were due to be reviewed and improved next.