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.

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 61 (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. After our last visit the provider, management and staff were committed to make the necessary improvements to bring the quality of care to the providers standards, vision and improve the culture. Staff spoke positively about the vision set by management. A staff member told us, “My unit manager has set a high standard that we all have to adhere too, this is a residential unit, so we make sure people are maintaining their skills. The unit manager has a very clear vision of ensuring all the residents have the best care. She knows all the residents and their care needs. She works by example too, if we say were running behind, she will help us straight away. People on this unit do receive amazing care.”

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. There had been a management change, and the deputy manager was now the acting manager. The provider and management team were compassionate leaders. However, we continued to not be assured the management team were always capable at identify risks, concerns and required improvements within their own processes as they did not identify the concerns we found prior to our visit in relation to the environment, medicine management and, staff not following care plans. The provider and management were reactive to respond to issues when highlighted to them, rather than proactively identify shortfalls within their own systems and processes. The acting manager told us they felt supported by the provider. People, staff and relatives spoke positive about the management. One staff member told us, “My unit manager is amazing, she is very capable and has the skills. I also feel the acting manager is capable too, because if I have anything to raise, they listen and take action.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt able to raise concerns and that they would be listened to. One staff member told us, “When it comes to me, I am comfortable about speaking out and we are always able to be open, and they [management] are approachable. Action is taken when I have raised anything.”

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. All staff told us they were treated fairly. One staff member told us, “I had to have some time off for sickness and they [managers] were amazing. Also, when I was ready to come back to work, you come back at your own pace.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. At time of our assessment there was not a CQC registered manager. The deputy manager was promoted to acting manager who told us they were going to become the CQC registered manager. The provider had a service improvement plan in place showing actions had been completed. However, the quality assurance and governance arrangements in place were not fully embedded or effective in identifying shortfalls found at the service as part of this assessment. 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 there was not an effective oversight in place to ensure people had received care in line with their care plans. Environmental checks failed to address issues and concerns we found during our assessment. Medicine audits failed to identify the concerns we found. Improvements had been made to records of people’s care were completed contemporaneously. This enables the provider’s systems to analyse events accurately. Improvements had been made to obtain people’s and relatives feedback to drive up improvements. Communication methods had been implemented such as newsletter to keep people informed of changes within the service.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. There was an effective processes and systems in place to work collaboratively, and share required information with health professionals. Further work was needed to ensure all reportable incidents are reported to the CQC and/or the local authorities safeguarding team where required.

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 had completed learning since our visit and was promoting a culture of best practice and worked towards making the necessary improvements. The provider had introduced new systems and processes to provide better oversight of the service. The acting manager was confident when the systems and process for oversight were embedded it would improve identifying risks and improvements would be identified through their own processes. The acting manager was receptive to the feedback and demonstrated commitment to improvements. Throughout the assessments they took action when we feedback the risks and concerns.