Lady Jane Court Care Home

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

There was an open and positive culture within the service where staff felt valued and respected. Leaders demonstrated commitment, experience and enthusiasm in continually developing and improving the service. The provider had systems and processes that supported partnership working to collaborate for improvement. The management team were committed to making improvements across the service. There were governance systems in place which assessed and managed the safety and quality of the service.

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.

Staff confirmed they knew and understood the provider’s vision and values. Staff told us there was a positive staff culture and that they felt valued and respected. A staff member said, “ I feel valued and listened to, it’s a good place to work. The aim of what we do is to provide a caring environment, where independence and choice is promoted.” The registered manager told us how they were working towards developing an excellent / outstanding service, that provided home from home care based on individual person centred care.

The provider had a clear strategy, vision and values in place that underpinned the service provided. This was shared with staff and consistently measured by the provider’s robust systems and processes that assess, monitor and review the quality and safety of care and support provided.

Staff were clear about their roles, responsibilities and accountability. Staff felt well supported and spoke positively about the opportunities for personal development and progression. A staff member said, “I'm very pleased with the new manager, very approachable, supportive, well experienced and gives clear guidance. We all know what our roles and responsibilities are.”

There were robust recruitment procedures in place to ensure the safe recruitment of capable and competent staff. Senior staff and leaders within the organisation were clear about their roles, responsibilities and accountability. Systems and processes confirmed provider oversight and leadership. During the assessment the regional support manager and director attended the service to support the registered manager and to assist with the assessment. They demonstrated commitment, experience and enthusiasm in continually developing and improving the service.

Staff were positive about working for the provider and how well the registered manager supported them. Staff felt valued and listened to, they were encouraged and enabled to speak up if they had any concerns. Staff confirmed they had access to the provider’s whistleblowing policy and that there was a positive and open culture within the service. A staff member said, “The manager has an open door policy and is very approachable, things have improved greatly since he's been here, systems and processes, ways of working are more streamlined now.”

The provider had workforce systems, policies, and procedures in place to support staff in speaking up and raising concerns. This included up to date policies in relation to safeguarding and whistleblowing. Staff were provided with opportunities to raise issues or concerns, such as during staff meetings scheduled over various days and times to ensure all staff are able to attend.

Staff were positive about working for the provider and the management and leadership of the registered manager. Staff confirmed they were respected and treated equally. Some staff choose to work long shifts and others shorter, they confirmed their working pattern was their choice. A staff member said, “Some staff do long days others shorter days -it's up to you.” The registered manager told us how they supported equality, diversion and inclusion within the staff team.

The provider had policies and procedures that protected the human rights of staff and ensured good working conditions. This included a flexible working policy. Staff could also opt out of the working time regulations. The staff rota considered staff’s shift and work pattern preferences.

Staff were clear about their roles, responsibilities and accountability. Senior care workers confirmed they had received additional training and support to undertake their roles. Staff were aware of the provider’s general data protection regulation (GDPR) policy and the importance of confidentiality. Staff had access to the provider’s emergency plan that included contact details in the event the service was impacted. Staff had access to both electronic and paper records and they explained what their role and responsibility was in completing records.

The provider had robust systems and processes that continually assessed, monitored and mitigated risks, safety and quality. Daily, weekly and monthly audits and checks were completed internally by the management team. The senior leadership team had direct access to these records for oversight. The regional support manager and director also attended the service regularly and completed sample audits and checks, action plans would be developed for any shortfalls identified. These detailed actions required by whom and within what timescales. Actions plans did show some overdue actions, but we felt sufficiently assured these were being addressed. Records confirmed unannounced night time spot checks were completed to ensure care standards and safety were maintained. The provider had quality assurance processes that enabled people, relatives, staff and professionals to share their experiences of the service. At the time of the assessment, the provider had recently sent a survey out and was awaiting for returns to analyse. The registered manager advised any actions would be followed up and the response of the survey shared. Monthly resident and relative meetings were arranged to further support and enable people and their relatives to share any suggestions, reflect on the service and to gain information from the staff. The provider had a GDPR policy and procedure in place. Care records were both electronic and paper records. The provider had a contingency plan that provided information and guidance to staff if the service was impacted. Following a fire service audit in 2023, actions had been completed as required. We found copies of 4 personal emergency evacuation plans (PEEP’s) to be missing, they were on the electronic system. We raised this with the registered manager and this was followed up immediately. The registered manager and provider understood their regulatory responsibilities and had submitted statutory notifications as required.

Feedback from people and their relatives confirmed communication was good and they were confident staff worked well with external health and social care professionals.

Staff spoke positively about the registered manager ‘s experience, knowledge and guidance they provided staff. They confirmed learning and new ways of working were discussed with them. Staff also confirmed how they worked with external health and social care professionals to support people to achieve positive outcomes.

External professionals were positive about partnership and collaboration with the service. They confirmed referrals for assessment and guidance were appropriate and made in a timely manner. Professionals also confirmed recommendations were followed by staff and managers within the service.

The provider had systems and processes that supported partnership working. This included developing a positive and professional relationship with external agencies. The GP visited weekly and these meetings were planned and organised. The staff recognised when external support and advice was required and knew how to make referrals when required. The registered manager accepted advice and guidance and was found to be open and honest during the assessment, showing a commitment and desire to further develop the service. The registered manager attended internal and external meetings and events to keep their practice up top date and to share and learning and development.

Feedback from staff was positive about internal communications, systems and processes that enabled learning opportunities. Staff confirmed the daily 10/10 heads of department meetings, staff handovers, staff meetings and supervision were used by the management team to share information including any learning and new ways of working.

The registered manager and provider kept up to date with best practice guidance and any relevant learning and improvement by attending external forums such as opportunities hosted by the local authority and east midlands care, a local long term care sector support service. They additionally received news and alerts from CQC and NHS. The provider also arranged regional and national meetings and conferences that included shared learning ,innovation and best practice guidance.