Jackson 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 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 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 service's values were clearly defined within the staff handbook, providing staff with guidance on the expectations and principles underpinning care delivery. The registered manager told us the service focused on promoting independence, working in partnership with people to understand what was important to them, and setting and reviewing person-centred goals to achieve desired outcomes. During our assessment, the management team operated a transparent culture around the shortfalls in the service and acknowledged improvements needed to be made. They were committed to acting on their service improvement plan.

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. 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 limited oversight of Jackson House, which reduced the effectiveness of quality assurance processes within the service. Auditing and monitoring systems had not always provided sufficient scrutiny to identify concerns promptly or support the timely implementation of improvements needed to maintain safe and effective care.

However, the management team demonstrated a commitment to driving continuous improvement for people and staff. More frequent quality monitoring visits had been put in place since our site visit to strengthen quality assurance processes and the registered manager had recognised personal areas of development. Advice and support was also sought from an external consultant.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Regular staff meetings were held and the registered manager encouraged staff to speak up and share concerns. The registered manager described how they were working to develop an open and transparent culture where people felt able to raise issues and were assured they would be supported and protected when doing so. Staff told us they could speak up. One staff member said, "I would go to my manager or my senior manager and if they didn’t take action, I would go to CQC."
 

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.

Staff had received equality and diversity training and were supported through regular supervision. Staff reported they had not experienced discrimination within the service and benefited from flexible working arrangements.

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.

We identified some shortfalls in the service's auditing processes. Although audits were completed, they did not consistently identify areas for improvement, including some of the issues found during our inspection. Where improvements had previously been identified, action had not always been taken to address them. This had been identified by the management team, and a new audit schedule had been introduced, alongside a process for collating findings into a centralised action plan to strengthen oversight, accountability, and continuous improvement.

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 evidence of positive partnership working with external professionals. Staff worked alongside other services such as GPs to support people with complex healthcare needs. The registered manager had also taken steps to develop and strengthen relationships with partner agencies to promote safeguarding, collaborative working and help ensure people's needs were consistently met. The manager had oversight of referrals, and any guidance and outcomes were shared with the wider staff team through daily handover meetings to ensure continuity of care. External professionals reported no concerns regarding the quality of care and support provided by the service.

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.
The registered manager had identified areas for improvement and was actively implementing new strategies. For example, creating a digital transformation programme to ensure staff were utilising their care management system to its full potential. Whilst we had identified missed opportunities in learning, the registered manager was receptive to feedback and had begun taking action to address issues identified during the inspection.