Yohden Hall Care Complex

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 remained 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 61 (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. Staff were able to describe the culture and values of the service and said they were proud to work there. One member of staff said, “The team here are all so lovely, they are so warm and welcoming and work really well together.”

Leaders had not always effectively addressed issues at the service. We found previously outstanding repairs to maintain the safety and integrity of the building had not progressed despite this being raised by visiting professionals on several occasions.

People, relatives and staff spoke positively about the leadership of the registered manager, who they said was supportive. One relative told us, “The manager is always around, she always speaks. No complaints up to now but, yes, I would probably go to the manager if I had to.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People, relatives and staff said they would be confident in raising issues and felt action would be taken if they did. A whistleblowing policy was in place, and staff received training in this area.

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. Regular meetings took place at which staff were able to discuss any concerns they had.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not consistently act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. At our last assessment we found that good governance processes were not in place. At this latest assessment we saw that the roof of the premises had been leaking for a number of years, which had been identified on action plans as early as 2022 but had not been addressed when we visited. On a recent provider audit of the service from February 2026, it was identified that the premises 'Need painting and redecorating' but with no timescale for completion. A number of audits were carried out to monitor standards at the service, but these had not always identified or resolved issues. For example, audits of care plans were routinely scored as ‘100%’ compliant despite the issues we found with medical health care plans and food and fluid records.

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. Healthcare partners did not raise any concerns with us on the effectiveness of the provider’s partnership working. A relative told us, “[Named person] sees the community dentist, sees the GP and any regular medical staff.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. 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, effective practice and research. Long-standing issues with the safety and condition of the premises had not been addressed despite action plans having been put in place in 2022. Whilst the issues was known to the provider, they failed to acknowledge the significance of this, and the risks posed to people. As a result, timely action had not been taken to fully address the issue and the risks posed.