Yewtree Care Limited t/a Yewtree Nursing 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

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 a legal regulation in relation to good governance.

This service scored 54 (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 promote an inclusive and supportive culture where people were fully involved in decisions about their care or supported to achieve the best possible outcomes. The manager told us the organisation’s values were discussed during induction, team meetings and supervision. During the inspection we did not always see staff apply these values into day-to-day practice. For example, people did not always receive dignified, person-centred care. Staff supervision and training were not always effective in helping staff understand people and their communities. This meant staff were not always equipped to provide care in line with people’s needs or best practice guidance.

The service did not have a manager registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. The manager told us it was their intention to apply to CQC to become the registered manager of the service.

Leaders, including the provider, did not always demonstrate the skills, behaviours or integrity needed to lead the service effectively. The manager was knowledgeable about clinical matters; however, they did not always demonstrate a strong understanding of regulatory responsibilities, best practice guidance or relevant legislation in non-clinical areas. There were occasions where the provider’s actions lacked full transparency. For example, some people were placed in shared rooms although this was not part of their commissioned care and required notifications to the local authority when people moved bedrooms were not always made. We informed the relevant local authorities about the people affected.

People and visitors described the manager as approachable and attentive. We observed positive and respectful interactions between the manager, staff and people, and people appeared comfortable and at ease with them.

The provider fostered a positive culture where people felt they could speak up, and their voice would be heard. Policies and procedures were in place to enable people, staff and visitors to provide feedback about their experiences of the service. Processes were available for people to raise concerns anonymously or with support such families or wider support networks. Staff were aware of the procedures for raising concerns both within the organisation and with partner agencies and said they felt confident to do so.

The provider valued diversity within the workforce and promoted an inclusive and fair culture. Policies and procedures supported equality, diversity and inclusion, and reflected relevant legislation and best practice guidance. Recruitment processes promoted fairness and ensured equal employment opportunities for all applicants.

Staff told us their individuality was respected and that they were treated fairly within the organisation. They described a positive and inclusive culture that recognised and celebrated diversity. Staff working on UK health and care worker visas told us they felt well supported, had good employment conditions and enjoyed working in the service.

The provider did not have effective governance systems to assess, monitor and drive improvement in the quality and safety of the service. There was a failure to ensure clear responsibilities, roles or systems of accountability to ensure good governance.

Quality assurance checks were undertaken by a designated member of staff; however, these were more of a check list that an audit. They lacked detail and did not identify actions or monitor outcomes. There was no evidence of provider or manager oversight, analysis or action. This had led to a failure to recognise the inconsistencies and risk we identified within people’s care records and care.

The provider had limited oversight of staff training and could not access the individual training records, certificates or completion scores requested during the inspection. These records were not made available to us during the inspection process despite our requests and undertaking a third in-person visit to the home to view them. There was no system to ensure staff had understood the various training modules or assessed as competent to put these into practice.

Governance shortfalls negatively impacted people with a learning disability. The provider and staff lacked understanding of the Oliver McGowan Code of Practice or their responsibility to adhere to this legislation. This meant they were not equipped to deliver safe, person-centred or lawful care to people with a learning disability and this had resulted in unsafe and inequitable care. Quality checks had not considered person-centred approaches to care planning. This meant a failure to recognise some care records were task focused and did not reflect people’s involvement, preferences or voice.

The provider did not always ensure the secure handling of personal information. Staff routinely accessed people’s electronic care records on their personal phones and told us they did not always log out when off duty. Sensitive clinical information was recorded in an unsecured book held an office within the communal lounge. Over the 3 inspection days we saw this office was never locked, and we observed on many occasions the book could be accessible to anyone in the area. Information in the book was not always transferred into people’s care records. Nurses told us they found it easier to write everything in 1 place rather than access people’s individual electronic care records. As a result, records were incomplete, and people’s confidentiality was not protected.

The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. The manager did not attend provider forums or manager network groups. They had not ensured people and staff had access to information and organisations about people’s specific genetic conditions, so that information and learning could be shared and used to improve people’s care experiences.

People had access to local health facilities and professionals for medical treatment.

The service did not always focus on continuous learning, innovation and improvement. They did not always encourage creative ways of delivering equality of experience, outcome, and quality of life for people. They did not always actively contribute to safe and effective practice and models of care were not always aligned to best practices guidance, including Right support, right care, right culture.