Jubilee Court Nursing Home

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 requires improvement. At this assessment, the rating has remained 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. We found ineffective processes and systems in place to assess and monitor the care being provided. Systems to audit the quality of care and safety were not always effective in identifying and addressing areas of concerns, risk, or improvements.

This service scored 54 (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. The provider had not completed their own reviews or checks of the service to ensure their vision, strategy and vision was followed by the staff team. The management team did not have a process in place to ensure care was always delivered to meet people’s assessed care and support needs. For example, safeguarding concerns were not always identified and reported; we identified significant concerns in reporting incidents and accidents and debriefing the staff team. These increased risks of the service not always having a positive listening culture.

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. The management team 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. During this assessment, we identified breaches of the legal regulations. This meant the management team had not always identified and taken action to ensure people received care that was in line with legal requirements. The provider and management team were compassionate leaders. However, we were not assured the management team always had the skills and knowledge to understand their role and responsibility. We found care and support was not always delivered in line with good practice and national guidance, as stated within safe of this report. This placed people at the risk of harm.

Staff, people, and relatives told us they felt they could raise any concerns, and they would be acted on. The provider, registered manager, and the whole of the management team where approachable. Managers encouraged an open and transparent culture where people living at Jubilee Court, their relatives, external health and social care professionals and staff were encouraged to raise concerns and without fear.

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 management team understood the importance of having a fair and inclusive workplace for all staff to work in. Staff were provided support through relevant training to inform their knowledge and understanding of equality, inclusivity, and fairness.

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. During the assessment we found the provider did not have effective systems and processes in place to assess and monitor the care being provided. Systems to audit the quality of care and safety were not always effective in identifying and addressing areas of concerns, risk, or improvements. For example, we found processes and systems to review the medicines management were ineffective. We were also not assured all staff were competent with medicines management. This placed people at risk of not receiving their medicines safely and at risk of harm. There was a lack of management oversight of staff competency to manage and administer medicines. The management team did not identify issues regarding staff competency. The failure to identify areas of concern and failure to act to address issues places service users at risk of receiving unsafe medicines. Furthermore, we found poor oversight of care planning, risk assessment record keeping, health and safety and staff training. The care plan audits and reviews failed to identify missing information, contradicting information and information that was not reflective of people’s care and support needs when changes had been made.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. The management team did not always share information and learning with partners or collaborate for improvement. We found shortfalls of the oversight of incidents and accidents. We found reportable incidents had not always been reported to the CQC and/or the local authorities safeguarding team where required. This meant people were placed at risk of harm/and or abuse due to poor reporting of safeguarding incidents. We found the management team had a strong and effective partnership working with health professionals.

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 systems and processes in place were ineffective in improving care and encouraging a culture of continued learning. We found the processes of quality monitoring to identify learning and improvement of the service was not effective. While staff told us there was a learning culture, we found systems in place such as care plan audits, medicine audits and incident oversight were not always effective at identifying learning opportunities.