Archived: Eboracum 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

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 requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

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

This service scored 36 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Staff told us that the management team were approachable, however, they did not feel their concerns were always acted upon when these had been raised.

Quality monitoring visits undertaken by the nominated individual had not highlighted concerns we identified during our assessment.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Organisational processes had failed to ensure the management team had worked effectively to ensure safe delivery of care and robust governance processes.

People did not always feel they could speak up and that their voice would be heard.The provider's complaints process was displayed in the service. People and relatives told us they knew who to approach and how to raise any concerns. Staff told us they did feel comfortable approaching managers however they did not feel that their concerns or suggestions were listened to or acted upon.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The processes in place at the service had failed to ensure that staff feedback was used effectively or that action was taken to ensure staff felt valued.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider failed to implement and operate effective risk management systems and to assess, monitor and mitigate risks to people. We found various shortfalls in the governance of the service, for example medicines management, infection control, environmental risks and assessing and reviewing people’s planned care and risk assessments were not audited or monitored effectively. There was a lack of effective leadership in place to ensure that governance and auditing processes were completed accurately. The audits in place at the service had failed to identify concerns at the service.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Processes in place at the service had failed to ensure information recorded about people was always up to date, accurate or sufficiently detailed. This meant when information was shared about people between services the quality of this information could not be guaranteed.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. During our inspection the provider was open and honest with us about the improvements required. They had recognised the concerns we identified and had formulated various new systems and action plans. These required a period of time to be completed, embedded into practice and sustained.