Justintime Healthcare

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 a legal regulation in relation to good governance.

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.

The registered manager explained how they shared the vision and values of the service. They told us this was embedded in the recruitment and induction process for staff. There was regular communication and training updates for staff. The provider’s statement of purpose set out the aims and objectives for the service to ensure people had positive experiences and received high quality care. Our conversations with staff confirmed they upheld the values of the service. Staff meetings were used as an opportunity to refresh knowledge, identify lessons learned and as an opportunity to discuss ideas to improve the quality of care.

Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

The registered manager had recently undertaken a recognised management qualification and had maintained their competence to be able to train staff with medicines and moving and handling.

We received mixed feedback about the management of the service. Whilst some people and relatives were very positive, others did not think the service was well run. Comments included, “It is very well managed. [Registered manager] rings me regularly and checks if everything is all right. They are always checking up on me and this means a lot to me” and “They need a big shake up in management.”

Feedback from staff was also varied with some highlighting they found the registered manager approachable and responsive and others who said they did not always feel listened to.

The provider had a Whistleblowing Policy in place. However, not all staff were aware of the policy and how to raise a concern. Comments included, “Whistleblowing is speaking up about things anonymously but I don’t know how to do this.” Whilst we found the polices were available to staff, knowledge of whistleblowing had not been embedded into the culture.

The provider had a positive approach to learning, with a culture based on openness and willingness to learn. People and relatives told us they knew how to raise concerns and felt confident appropriate action would be taken to address them.

Accidents and incidents were reported by staff, including near miss events. There was a complaints log in place which showed timely responses and the action the provider had taken to resolve any concerns or complaints. Most people and relatives told us they knew how to raise a concern and who to contact. The provider had recently upgraded their electronic systems which meant information was clearly collated to demonstrate lessons learned and action taken. We saw examples where details of events were shared with staff in team meetings and additional training and support had been provided.

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.

Effective systems and processes were not in place to assess, monitor, improve and sustain the quality and safety of the service. Quality audit systems were not always effective in ensuring improvements were made and sustained. Action plans were not always completed promptly. For example, key safety areas identified in an external audit carried out in March 2025 had not been fully addressed, and we found regulatory breaches relating to the safe management of medicines and good governance.

Medicines audits and care plan audits had not been effective in identifying the shortfalls we found at this assessment. For example, care record audits had not identified the shortfalls in peoples’ care records. Medication audits had reviewed some of the same records the assessment team reviewed and their findings were inaccurate. This meant we were not assured auditing processes were robust.

The provider had policies in place, which had been recently reviewed.

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.

The provider worked in collaboration with other agencies, including GP’s and other health and social care professionals.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

The provider had not demonstrated continuous improvement and the overall rating at this assessment had changed from good to requires improvement. The provider acknowledged there were areas which required improvement and there was a Service Improvement Plan in place which had highlighted some of the shortfalls we found at this assessment. The service had recently introduced a new electronic care planning and call monitoring system and acknowledged they were still developing their knowledge about how this could be best used to improve service delivery. They were confident, when fully in place, systems and processes would be strengthened and quality would improve. The provider worked closely with the staff team to ensure lessons learned were shared in team meetings. The provider had commissioned the support of an external agency to provide support and guidance.

The provider was receptive to feedback and demonstrated their commitment to improvement. They acted promptly on the feedback we gave throughout the assessment.