Emily 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

Quality assurance processes were effective in monitoring the quality and safety of the service. Staff told us they felt valued and were treated equally. The visions and values of the service were shared and there was a continuous strive to drive improvements. The management and staff worked with health care professionals to ensure people received co-ordinated, joined-up care and support.

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.

The provider’s ethos was embedded in the service. Staff told us they were aware of what the provider expected of them. Staff we spoke with were able to tell us about the culture in the service. One member of staff said, “It is an open culture here. Staff tell us when things happen and, in turn, we tell partners such as CQC or the local authority and the NHS.”

The provider had policies and processes in place putting people at the heart of their care and support. The management team worked with staff, through one-to-one supervisions and appraisals, to ensure each member of staff was confident and competent in their role. The Barchester values of ‘respect, integrity, passion, empowerment and responsibility’ were monitored and discussed during these meetings. The management team worked proactively to embed the values into daily life at the service.

The regional manager had a visible presence in the service. The manager who was overseeing the service whilst the registered manager was away from the service told us, “Being a new manager I have to say that the provider’s onboarding and induction is one of the best I have ever been through. I have been supported so much from the staff, the regional director, and registered managers of the provider’s other registered locations.”

There were systems in place to ensure management and staff were working in line with expectations. The registered manager had regular reviews of their performance with the regional director. The management team were visible and had an open-door policy to ensure people, relatives and staff could provide feedback or raise concerns.

Staff knew about the support system in place to enable staff raise their concerns or grievances. They told us that a ‘speak up’ person from the organisation had visited to share with them on how to raise their concerns or complaints about the service. They said they trusted that the provider would address concerns they raised appropriately and fairly.

Clear whistle-blowing policies and processes were in place. To support this, the service also had ‘speak up champions’ to help encourage staff to share areas of concern and highlight areas of good practice. They completed training on how best to support staff and escalate concerns. Where staff had raised a concern with the speak up champion, this was investigated and, when needed, acted upon.

Staff felt they worked with people from diverse backgrounds and ethnicity. The provider operated a talent mapping process. This was where staff who were doing well in their roles were recommended for promotion. We were made aware of a member of staff who was recruited from overseas that was doing very well in their role, and this had been recognised. They were currently going through a recruitment process for a promotion.

There were policies in place to ensure legal obligations to staff were met and to work towards a fair and inclusive culture. Staff completed equality and diversity training. Workforce wellbeing was promoted at the service. Staff had access to a range of health and wellness support services to aid their wellbeing. An ‘inclusion group’ had been set up where staff, passionate about equality, diversity, and Inclusion, worked together to ensure staff felt a sense of belonging and were respected as individuals. Staff celebrated numerous events throughout the year, such as Pride month.

The manager and regional director told us about the providers governance systems. The manager felt that these enabled a higher level of support for them in their position. All accidents, incidents, near misses and complaints were uploaded to a central provider wide system. This allowed senior managers and clinical leads to have oversight of the service. We were told this led to the clinical leads identifying and themes, trends or training shortfalls which could be quickly remedied. The deputy manager told us that some incidents were triaged out and did not require the scope of investigation that the provider’s processes detailed. They said, “Some do not require the upload to our system. This shows the staff are really good at raising and reporting any concerns they have. We try to deal with as much as possible locally but are always open and honest about things which have happened.” Staff told us the management of the service was good. They knew who to speak to if they had concerns. They told us they were given the support to do their jobs effectively. All the staff we spoke with told us Emily Jackson House was a good home and they would put their loved ones in the home.

The service was led by a registered manager. They were not at the service at the time of our assessment, however there were contingency plans and a manager from another of the provider’s services was present. There were quality assurance and clinical governance systems in place to monitor the safety and quality of the service delivered. The management team reviewed checks and audits to identify any patterns or trends. When shortfalls were identified, action was taken to address these. Notifications of reportable incidents, such as serious injuries or deaths, were submitted to CQC in line with guidance.

People told us they received support from external health care professionals when needed. People enjoyed being involved with visits from the local community. There had been visits from school choirs and a local church.

The registered manager and staff had established good relationships with health and social care professionals. They shared records to help inform health professionals' clinical judgements. This meant that people received joined-up care.

Processes were in place to make sure referrals to health care professionals were made in a timely way. The management team and staff monitored changes and improvements when following advice and guidance from health care professionals. For example, a person who had a history of weight loss had been referred to a speech and language therapist. Advice was given to change the consistency of the persons meals. Staff followed this and it resulted in the person beginning to enjoy their food more and a healthy increase in their weight.

The regional manager told us, “Learning is the most important thing to us. Things will happen but it's about finding out why they have and what we need to do to reduce the chance of it happening again. When we have an incident or an accident or we get something wrong we complete reflective practice and hold supervisions to identify any learning. This is then fed back to all staff.”

The provider had processes in place to monitor the service, evaluate findings, learn lessons, and drive improvements. The service had begun to use a bespoke electronic care planning system which the provider felt ‘Aligns with our wish to deliver the highest quality individual care and life enrichment’. Staff had been trained and were confident in using the system and they were supported throughout the roll-out. There were clear processes for people, relatives, and staff to provide feedback and to be involved in improvement and innovation initiatives.