Jane House

Accidents and incidents were analysed but not frequently enough to identify current trends and patterns. We discussed this with the registered manager, and they took action to make improvements. The provider made appropriate referrals to the local authority to keep people safe. We discussed submitting notifications to CQC at the same time these referrals were made and the registered manager identified improvements to their reporting processes. People’s care plans were personalised and care and support was delivered in line with these care plans. The provider had appropriate and detailed risk assessments in place which identified the numbers of staff required to support people throughout the day. Risk assessments were reviewed regularly which ensured the appropriate staffing levels where in place. Medication administration was managed safely and people received their medications as prescribed.

The provider planned and delivered people’s care and treatment with them, including what was important and mattered to them. Members of staff supported people to live healthier lives and where possible, reduce their future needs for care and support. People’s capacity to consent to care was assessed and recorded in their care plans. Assessments were decision-specific in line with the Mental Capacity Act 2005 Code of Practice.

The provider always treated people with kindness, empathy and compassion and respected their privacy and dignity. People were supported to make choices about their day to day living and support. The provider cared about and promoted the wellbeing of their staff and supported and enabled staff to always deliver person-centred care.

Care was person-centred and each person's unique identity was supported and maintained. People received care and support from a consistent team of staff who knew them well. This ensured continuity of care and support. Members of staff involved people in decisions about their care and told them what had changed as a result. The service provided equitable care and support which ensured people, regardless of their communication abilities or complexity of needs, received personalised, respectful and consistent care. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

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. 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. Our discussions with the registered manage 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 provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. People were supported to access local shops and specialist services in the community.