Yew Tree Holdings Limited

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 the legal regulation in relation to good governance.

This service scored 57 (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. They had not consistently been engaged in the overall management of the service which meant they did not always understand the challenges and the needs of people. For example, issues with staff’s care delivery which had impacted on the quality-of-care people experienced.

The provider and deputy manager told us there was a split culture at the service which they were trying to address. The divide in the staff culture meant that staff teams were not always working effectively together to ensure people received consistent, safe and dignified care.

The provider did not have leaders at all levels; there had not been a registered manager at the service since May 2024, although the provider was actively trying to recruit a manager at the time of our inspection. There was no full-time management at the service to model a positive culture and values to underpin safe, effective care for people. This had impacted on the overall quality-of-care and governance of the service.

The deputy manager was passionate about people and their home and had the skills and knowledge to carry out their role effectively. They understood the context in which they delivered care and did so with integrity, openness and honesty. People, staff and relatives were positive about the deputy manager. Comments included “The management is approachable.” And “[Deputy Manager] is brilliant.”

The deputy manager had received some distant support from a consultant whom the provider sought additional support from following the inspection. Staff had told us the service had previously improved under the guidance of the consultant.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.Staff were aware of how to blow the whistle in relation to any concerns they had about the service or care provided for people. A staff member told us, “Whistleblowing is about raising awareness of a problem if you feel you aren’t being listened to. There is a good policy in place, and I am confident to whistle blow if needed, but I haven’t felt the need to.” A paper copy of the whistleblowing policy was in the office and accessible to staff who knew where to find this.

Relatives felt able to raise concerns with the deputy manager and felt these would be acted on. A relative said, “[Deputy Manager] responds quickly to everything. They deal with things as they arrive.” People, and relatives acting for them, were issued with information on the complaints procedure in a format they understood. There was a system in place to log both formal and informal complaints which had been responded to appropriately. The provider took action following complaints they received in order to improve service delivery and gave their apologies.

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. Staff told us, “There is no rudeness, no discrimination. The deputy manager used to be a carer so knows the needs of the job and the people well.” Another said, “If I need to change my shift for family reasons, they will help, they try their best.” Staff had completed equality, diversity and human rights training.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. There had been several management changes within the service which had negatively impacted on the overall governance.

The provider did not act on the best information about risk, performance and outcomes. The systems and processes in place had not always been consistently and robustly applied to support the management of the service. Issues with the washing facilities had not been identified, the management’s home-environment audit had not been completed recently to enable them to identify concerns.

Audits which had been completed to monitor the quality of the service had not been effective and did not identify the issues we found at this assessment. For example, although people’s care plans had been regularly reviewed, the reviews had not identified lack of risk assessments or detailed guidance. Some recently reviewed care plans still contained out of date information. This demonstrated the governance and management systems were not being applied robustly or effectively. The recent medicines audit also did not identify the issues with medicines storage and recording that we found at this assessment.

Records were not always up to date, accurate or complete. This included risk assessments, care plans and records of the daily care people received such as routine welfare checks on people or records of people’s fluid intake. This meant the provider did not have effective oversight of the care people received to ensure it was sufficient to meet their needs and mitigate risks for them.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.People and relatives told us there was good access to other services to meet people’s needs and improve health. A person said, “I used to have a stocking on my leg, but that’s better now.” Staff worked with other health and social care professionals to manage risk and meet people’s needs such as the Dementia team, Speech and language therapists and Palliative nurses.

Professionals who worked with the service were positive about the partnership working. A professional told us, “The management have contact via email and provided updates at professional meetings.” Another professional spoke positively about a persons experience of care and positive outcome. They said, “Yew tree lodge have managed a very complex case with professionalism and dedication to ensure the best interest of the client was reached. They provide support beyond what was commissioned, and all staff provided additional support from management to care staff. The outcome was successful."

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research.

Without robust and effective oversight of the service through the governance processes in place, the provider had limited ability to identify areas for improvement or to continuously learn. Areas for improvement which had been identified through the quality assurance processes had not been embedded and maintained. For example, staff were required to carry radios when on shift, but the deputy manager told us this was not being consistently completed. We reviewed records of feedback gathered from people and relatives by the provider in April 2025. Feedback was that they wanted music from people’s generation however modern music was playing in the quiet lounge of the service. Accidents and incidents were reviewed however learning had not been consistently implemented to reduce future risk.

However, staff were eager to learn and improve during the inspection. A staff member told us, “Learning and improvement are ongoing."