Jane House

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 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 remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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. The registered manager had a clear vision for the service which was understood and shared by members of staff. The service had the culture and feeling of a family home where people lived their lives as they wanted and did things they chose to do.

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 registered manager was well organised and they empowered the staff team to lead and manage the care home. The registered manager understood the people who lived in Jane House supported them to achieve their dreams and aspirations. A member of staff told us, “The registered manager is around most days. I have regular supervisions and appraisals. They are also available anytime if I want to ask something or require support.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Members of staff had access to a whistle-blowing policy and told us they were able to speak openly and suggest new ideas about delivery of care and support. One member of staff said, “I am able to suggest new ideas or other ways to provide support. [The registered manager] is always available to listen.”

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. We were not made aware of any concerns about discrimination within the service. There was a positive workplace culture where people and members of staff were treated with dignity and respect, regardless of their background or personal characteristics.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. Our discussions with the registered manager and provider identified some areas for improvement around submission of notifications to CQC and analysis of accidents and incidents. The changes and improvements needed to be sustained and embedded into practice. The service had a clear system of audits and reviews which were completed regularly by a member of the management team. The registered manager maintained oversight of quality in the service through reviews of people’s care records including care plans, daily notes, medications administration records and outcomes from health and care appointments.

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. People were supported to access the local shops and specialist services in the community. There were good links with health and care professionals which ensured care and support for people was joined up and effective.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. Whilst accidents and incidents were reported and analysed by the registered manager, the frequency of analysis could be improved so more current data about themes and trends could be identified. This would enable the registered manager to make any changes or improvements to the running of the service and maintain the focus on continuous service improvement.