The Jessie May Trust

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

We reviewed the governance, management and sustainability quality statement for the well-led key question. Governance, management and sustainability: audits were conducted and highlighted issues with keeping records updated. There were systems to ensure safe care. However, it was not always clear who held responsibility for regulated activities.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

At the time of the assessment, the service was updating their Service Level Agreement (SLA) with the local hospital. Under the new SLA, the clinical team would be managed by the local hospital and it was not always clear who held the responsibility for the regulated activities and who was accountable for the actions, behaviours and performance of clinical staff. The new SLA also meant that 16 families living out of area would no longer be cared for by the clinical care team from the local hospital. However, there was a plan to mirror this agreement with another hospital geographically closer to these families and a 12 month transition period had been implemented to allow the original hospital team to support these families until the new agreement with the second hospital was embedded. Most staff we spoke with talked about a “one team” approach between clinical and non-clinical staff and told us they were confident to speak up if they needed to raise a concern. All staff were clear on their responsibilities within the organisation.

Senior staff conducted audits on the services provided. However, follow up on actions at quality assurance was not always clearly documented and some staff were not aware of learning from audits. Audits highlighted issues with keeping record systems up to date and most staff felt the record system could be improved. Staff told us that there were often delays getting updates to care plans into the system due to the paper records. However, the service had systems for safe care, with detailed handovers clarifying the children’s care plans with families ahead of visits. Record systems were listed on the service’s risk register. This was comprehensive and leaders were fully aware of the organisational risks. However, the provider did not have a policy to support their risk management framework. There were policies for data protection and staff understood them. There was a complaints process and most families knew how to raise a complaint if they needed to. However, most families told us they had never needed to make a complaint. All staff knew how to report an incident and said they felt shared learning from reports was improving with meeting times being protected. Staff told us new governance processes were in place to review incidents.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.