Joseph 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

Systems and processes designed to oversee the safety and quality of the service were not always robust. We identified concerns relating to fire safety, staff knowledge, oversight of some health conditions, consent, auditing and overall culture of the service. External professionals questioned the culture of the service, which they found risk averse and not encouraging of people’s independence. We also found this to be a concern. The lack of effective oversight in a number of areas constituted a breach of Regulation 17 of the Health and Social care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the individual sections below.

The provider, who was also the registered manager was often at the service and was held in high regard by staff and by the majority of relatives we spoke with. The provider was very open to our feedback and immediately began to review the concerns we had raised, and sent us a detailed action plan immediately after the onsite visits were concluded.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they felt there was a positive culture at the service but, when asked to explain this, commented on the fact that it was safe and there were plenty of staff. This was true but, despite knowing the people they were supporting well, in most cases, staff did not mention people’s goals, aspirations or rights. Staff told us they felt safe to voice their opinions with the provider, but we saw no evidence in records of where people had challenged aspects of the service or made suggestions.

The vision, strategy and culture of the service was not clear. The provider’s website, which they acknowledged required updating, stated the majority of the people who used the service were older people. This was not accurate. Most people were younger and were living with a learning disability or required mental health support. The culture for these people was task based, risk averse and lacked forward vision. The provider told us they planned move towards some individual independent units. However, limited action had been taken in respect of this, although we acknowledged the constraints of the historic building. People were monitored closely to try and keep them safe. There was a lack of acknowledgement, whilst taking into account their complex needs, people were adults. At one point the provider, although being clearly very committed to the service and the people who used it, said, ‘[They] are children in an adult body – without being derogatory.’ We found limited evidence of people being supported to increase their skills and independence and processes did not drive this. Staff were not proactive, and their language reflected a culture of people being 'allowed' or 'not allowed' to do things. The provider told us they were introducing a keyworker scheme aimed, in part, to have better oversight of people's goals and aspirations. People were going out but, given the staffing levels, access to the community did not always reflect what people had written in their care plans. Some aspects of the service felt more like a secure unit and quite institutionalised. Staff mostly monitored people rather than engaging with them and this was not challenged. Communal flannels and towels added to an institutional feel to the service and were not appropriate for people.

Staff gave very positive feedback about the registered manager and deputy manager and felt they were a strong management team. Agency staff told us they felt comfortable going to the management team for advice and, in their absence would ask other colleagues who were very supportive. The deputy manager and registered manager worked well together and were supportive of each other.

Although there was support for the registered manager and she was held in high regard by many, most of the concerns identified during this assessment related to leadership. A variety of systems and processes required a review to ensure they were sufficiently robust. This was acknowledged by the registered manager who provided CQC with immediate assurances about the concerns we had raised during the course of this assessment.

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.

Senior staff completed audits, but these were not always effective in identifying and acting on issues. Two senior members of staff had completed audits of people’s weights, but no action had been taken in response to one person’s significant weight loss. The registered manager and provider told us the poor oversight was partly due to a staff member leaving. However, this remained a concern as their replacement had also not followed up.

Staff documented people’s continence daily but robust oversight of this was not in place and staff were not clear who should be raising concerns if needed. Body maps had been completed where people had sustained injury or bruising. However, staff struggled to navigate records to see what investigations had taken place and establish the outcome. This was partly due to the service having only recently introduced the new electronic recording system and the deputy manager told us things had already begun to improve.

Staff were positive about the management team and felt they supported them well. Agency staff were comfortable with having line management input from both the agency and the provider and felt accountable to both.

Audits of people’s weights, continence records and body maps did not always ensure investigation took place in response to concerns. Staff required more in-depth training both on their responsibilities and on the new system. The provider has already begun to address this issue. Staff did not have access to the service's business continuity plan which set out arrangements and key contacts should there be an emergency such as a problem with the building meaning people needed to leave. The provider stated the management team kept the plan and all lived locally.

Given the high dependence on agency staffing, oversight of these staff could have been more robust. On our out of hours visit to the service we found the entire night staff team was from one agency. Most of these staff had been coming to the service consistently for months or years, although a few were relatively new. There were no permanent staff working the night shift, but the provider did not undertake formal audits to check on the quality and safety of the service at night. The provider told us the agency did out of hours visits but the results of these were not routinely documented and shared. Since our onsite inspection visit the provider has begun a programme of night audits. Other audits were in place to effectively monitor aspects of the service including medicines, maintenance and cleanliness.

People’s relatives gave mostly positive feedback about their experience of working in partnership with the service. One relative explained the collaborative approach they had experienced when a concern about their family member’s health arose. They said, ‘We all had a team meeting with the way forward recommended by [the] consultant. It was very helpful, and I was pleased by [the] outcomes. All I know is that staff from Joseph House are following recommendations.’

Staff were positive about how the service worked in partnership with other health and care providers. Most partnership working with external colleagues was carried out by the senior staff and the majority of the staff team told us they followed whatever guidance was agreed upon. Staff, including agency staff, said they felt able to share issues within the service’s staff meetings which were open to all.

We received minimal feedback from partners and feedback was mixed. One person stated, ‘During the visits to Joseph House, the staff didn’t understand that we were there to support them or felt like they could ask questions. It was a frustrating process…… It is very difficult to maintain that positive view of the establishment. They don’t seem to get on board or see the importance of the recommended changes.’ Other professionals told us they felt the service needed to modernise and grow but praised the willingness of the service to support people with extremely complex needs.

Processes to encourage partnership working were in place and the provider told us they worked well with the local authority commissioning team. The provider sought feedback from other professionals involved in the service via a survey, but these were very brief and generalised and had not generated any action plan.

Staff, including agency staff, told us they shared ideas and feedback in staff meetings and supervision sessions. Those staff we spoke with were not familiar with the staff surveys we saw and had not been involved to give feedback in this way. We judged agency staff in particular were hesitant to question the practice of the service or offer suggestions. Staff told us they had their roles and their 1 to 1 responsibility but did not think in a wider context about the service. We observed a handover from day staff to night staff. Communication was brief from the day staff member and night staff asked no questions. 1 to 1 night staff accepted their assigned resident and went directly to them from a central location where the handover took place. This was not a two-way process in any meaningful way.

Processes were in place to request feedback from people who used the service, external professionals, staff and relatives. The quality of these was poor and gave limited information. They were not able to be analysed in any depth and comments were very general. The provider had analysed their own management style but it was not clear what impact this had had. The provider noted they were not satisfied with the surveys for people who used the service and would repeat them but this had not happened.