Yearsley Villa

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.At our last assessment we rated this key question good. At this assessment, the rating has changed to requires improvement.This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 50 (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 did not always have a clear shared vision, strategy, and culture to ensure high-quality, person-centred care. The providers described a flexible, family-style approach to care where people were supported to live independently and make choices about their daily lives. Observations showed people could come and go as they wished, and the provider described supporting people in a way that respected their preferences.However, this approach was not underpinned by clearly defined systems, oversight, or a shared understanding of regulatory legal requirements. Care records lacked detail and did not consistently reflect people’s needs, including mental health support and risks. The provider had not ensured their registration accurately reflected people’s needs, and there was limited evidence of how guidance such as right support, right care, right culture was considered. This meant that while a caring ethos was evident, it was not consistently translated into structured and effective systems to support safe, high-quality care.

Leaders were not consistently able to demonstrate the knowledge, skills and oversight required to ensure regulatory compliance and safe care. The providers knew people well, and interactions with people were observed to be kind and familiar. However, they did not demonstrate a clear understanding of their regulatory responsibilities. For example, they had not ensured appropriate recruitment checks were completed, did not maintain accurate or comprehensive care records, there was no clear evidence to support their knowledge and understanding of the Mental Capacity Act. During discussions, leaders were unable to provide clear evidence of processes they described, such as medication monitoring, and systems were either not in place or not recorded. This lack of leadership oversight meant risks were not always identified or mitigated, and the service was not consistently managed in line with legal requirements.

The provider had an open culture where people could raise concerns and share feedback.People appeared comfortable expressing their views and described being able to approach the provider directly. Feedback arrangements included contacting families and offering opportunities to raise concerns. People did not raise any concerns and leaders described an informal approach where people could raise issues at any time.

The provider treated people fairly and there were no concerns raised in relation to inclusion and diversity. It was a small, supportive team, and leaders described an informal and inclusive working environment. Observations indicated respectful interactions between the provider and people using the service.

The provider did not have effective governance systems to monitor quality, manage risks, or ensure compliance with regulations.There were no formal audits or quality assurance systems in place to assess and improve the service. Records were inconsistent, incomplete, or contradictory, and there was no system to ensure they were accurate or up to date.Risks were not always assessed or monitored, including in relation to medicines, finances, and mental health needs. In addition, incidents which required notifications to be sent to CQC had not been submitted, and there was no evidence of learning following events. Without effective oversight, leaders could not be assured that care was safe or improvements were identified and implemented, placing people at potential risk.The provider acknowledged feedback during the inspection and worked to update some records. However, more time is needed to fully develop, sustain and embed good practice and governance.

The provider worked with other professionals and community services to support people, although this was not always fully evidenced in records.Leaders described regular contact with external professionals, including mental health teams and healthcare services, and people were supported to attend appointments and maintain community links. People were able to access the community independently and maintain relationships with family members, which supported their wellbeing and social inclusion.

The provider did not have a culture of continuous learning, improvement, or innovation.There was no evidence of structured learning from incidents or audits. Records showed incidents had occurred, but these had not been appropriately reported or reviewed, and there was no documentation to demonstrate learning or changes to practice. Training was often out of date, and there was no clear strategy to ensure staff maintained up-to-date knowledge and skills relevant to people’s needs. This meant opportunities to improve the quality and safety of care were missed, and the provider was unable to demonstrate a proactive approach to learning and development.