Ingleborough 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. This is the first assessment for this newly registered service. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider had a clear vision and strategy that staff understood and worked towards. This was based on being open, fair and respectful of people’s rights. The management team encouraged an inclusive culture, and staff involved people and their families in conversations about their care.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The management team were described as kind, approachable and actively involved in daily care. Staff said the management team were visible and supportive, stepping in to help when needed. They felt listened to and treated fairly, describing the team as friendly and easy to talk to. Governance processes such as daily walk-rounds, 11am meetings and regular huddles showed the team understood risks, staffing and quality needs.

People and relatives also spoke positively about the management team, describing them as reassuring, kind and committed to creating a warm culture.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff said they felt able to speak up and knew they would be listened to. Comments included, “I know about freedom to speak up,” and “The manager encourages us to speak up every day.” Staff explained they reported anything they were worried about straight away. A whistleblowing policy was in place, and staff said they understood it and felt safe using it.

Relatives told us concerns were taken seriously, saying, “If I ever have a concern, they listen and sort it out.” Families also shared compliments about the service, describing staff as kind and supportive.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider valued diversity within the workforce and promoted an inclusive and fair culture. Staff said they felt respected and supported, with comments such as, “Managers are friendly, can speak to them anytime,” and “My manager is very good, they make sure everything is good.” Staff described strong teamwork and a welcoming atmosphere, explaining, “Everyone works together and helps each other.” Regular staff meetings were held, giving staff the chance to share their views, raise any concerns and contribute ideas. These meetings fed directly into management oversight and helped ensure staff felt listened to and included.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider had audits in place which supported strong governance and effective oversight across the service. Regular reviews of the environment, kitchen standards, infection control, care documentation, medication processes and daily care quality were carried out by the management team. Staff described these processes as well organised and consistent, noting that systems were checked daily to maintain safety and quality. Information from these checks was recorded on the electronic system, allowing the team to track actions, monitor risks and ensure consistency across the whole service.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked well with a range of external professionals to make sure people received consistent care. Staff said nurses regularly spoke with visiting General Practitioners (GPs), Advanced Nurse Practitioners (ANPs), and other professionals to keep everyone updated. The service also linked with district nurses, the dietitian, Speech and Language Therapy (SALT), Occupational Therapy (OT), Community Psychiatric Nurses (CPNs), behavioural support teams and the Leeds City Council Quality Team.

Regular multidisciplinary team (MDT) discussions helped share information quickly. Specialist support was brought in when needed – for example, SALT for swallowing issues, OT for equipment assessments, the Tissue Viability Nurse (TVN) for wound reviews and podiatry for routine foot care.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The management team reviewed incidents and accidents every day to understand what had happened and what needed to change. Staff said they were expected to report issues straight away. Incidents were discussed in daily huddles and during walk‑rounds, where trends such as falls or health concerns were reviewed. Actions were put in place and followed up to make sure improvements happened. Staff confirmed learning was shared with them and they were encouraged to speak up, saying, “We would report any changes. We have been told and in training what we should do and how she should report.”

This learning helped improve people’s daily experience, with the management team making changes wherever issues were identified to ensure care became more consistent and responsive.