Date of assessment: 26 August to 23 September 2025. The service is a care at home service, registered with the Care Quality Commission (CQC) to provide personal care to people living in their own homes.At the time of assessment, the service was providing support for 6 people who received the regulated activity of personal care. The provider, managers, and staff demonstrated an exceptional commitment to delivering person-centred care of the highest standard. People and their families were not just involved but empowered to lead the planning and review of their care, including the taking of positive, well-managed risks that enabled individuals to achieve meaningful goals and fulfilled lives. Care records were not only accurate but dynamic, consistently reflecting people's evolving needs, preferences, and aspirations. Leadership was effective, with a clear vision that placed people’s experiences at the heart of every decision. The provider proactively sought feedback, embraced learning, and embedded improvements in a way that continually enhanced outcomes. Staff were exceptionally well supported, their development and well being were prioritised and celebrated, contributing to a motivated and skilled workforce. The service’s culture was deeply inclusive, transparent, and values-driven, where every person, whether staff, people using the service, or their families, felt genuinely heard, respected, and valued.
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CJP Outreach Services Ltd is an Outstanding-rated domiciliary care provider supporting nine people with learning disabilities and complex needs, distinguished by deeply personalised, enabling support that has facilitated international holidays and lifelong ambitions. No failure themes were identified; the service improved from Good to Outstanding overall, with Caring and Responsive rated Outstanding and Safe, Effective and Well-Led rated Good.
Strengths
· Exceptional person-centred care enabling people with complex needs to travel internationally and pursue lifetime ambitions such as watching the Ashes in Japan and Australia.
· Staff retention of minimum six years, with one staff member supporting the same person for over ten years, fostering deep and trusting relationships.
· Highly individualised support with adaptive weekly timetables, contingency plans, and a 'no two days the same' ethos praised by the Director of Adult Services.
· Robust medication management including shared MAR charts with families and protocols developed with consultants and specialist nurses.
· Registered manager provided strong advocacy, supporting people's financial entitlements and attending professional meetings on behalf of families.
Quality-Statement breakdown (26)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityOutstanding
caring: Supporting people to express their views and be involved in making decisions about their careOutstanding
caring: Respecting and promoting people's privacy, dignity and independenceOutstanding
responsive: Supporting people to develop and maintain relationships to avoid social isolation; support to follow interests and take part in activitiesOutstanding
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesOutstanding
responsive: Meeting people's communication needsOutstanding
responsive: Improving care quality in response to complaints or concernsOutstanding
responsive: End of life care and supportGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving careGood
CJP Outreach Services Ltd was rated Good overall following an announced inspection in October–November 2016, with all key questions rated Good except Responsive which Requires Improvement. The main shortfall was insufficiently detailed care records that failed to capture staff knowledge about communication, personal care and capacity, though the registered manager agreed to address this.
Concerns (4)
moderateCare planning: “care records were not split into sections to increase details such as, communication, personal care, activities, medicines and mental capacity.”
moderateRecord keeping: “People's support records did not always contain individualised communication support plans to provide staff with the guidance they needed to communicate effectively.”
minorSupervision / appraisal: “The registered manager told us they had met regularly with people to perform spot checks, but had not always recorded this.”
minorPerson-centred care: “People's support records contained some examples to show where they had been involved with decisions about their care, although examples were limited.”
Strengths
· Relatives expressed high levels of trust and satisfaction with staff, with no safeguarding concerns raised.
· Safe recruitment processes in place including criminal record checks, references, and shadow periods.
· Staff completed mandatory training including safeguarding, medicines administration, and moving and handling.
· Medicines were stored, handled and administered safely with appropriately completed MAR records.
· Principles of the Mental Capacity Act 2005 were applied correctly, with three COP referrals made appropriately.