York 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 remained requires improvement. This meant the management and leadership was not always consistent.

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 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. However, several staff members told us about incidents that had happened with staff which reflected a culture where improvements were required how the team worked together. We did not see evidence of these issues having a negative impact on the quality of people’s care.

The provider was holding regular team meetings and supervisions with staff, however there was no evidence that staff’s views around low staff levels had been openly encouraged and discussed.

There was a stable management team at the home who were knowledgeable about people. However, additional work was required to ensure appropriate and consistent oversight was in place at all times. For example, after our first visit to the home, we shared feedback about people’s mealtime experience; on our second visit, we found the management team had gathered feedback from people and staff and rearranged the rooms in line with the preferences of people who were currently living at the home.

The provider understood their obligations for submitting notifications to CQC, as required by law. However, during our review of the Deprivation of Liberty Safeguards (DoLS) applications, we identified that a DoLS application for a person who was not safe to leave the service unattended had not been submitted; the registered manager took immediate action after this was identified.

People told us they felt safe living at the home. Staff told us they enjoyed working at the home and shared positive feedback about the registered manager. Their comments included, “Very supportive manager, she treats all staff well.”

The provider aimed to foster a positive culture where people felt they could speak up and their voice would be heard. Although staff told us they felt able to raise any issues with the registered manager, we found examples where staff were not clear on actions taken when concerns hadbeen raised. We spoke with the registered manager about the issues raised by staff, and they were aware of these, but not records had been kept of actions taken and lessons learnt. There were systems in place to seek people’s views as to the quality of service received.

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 they felt supported and said it was a positive place to work. There were policies and procedures in place to ensure the provider met their legal obligations to staff and work towards a fair and inclusive culture.

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

The provider's quality assurance systems had not always been effective in identifying issues found at this assessment and driving the necessary improvements. For example, medication audits were being completed and issues had been identified with PRN protocols before our visits, but we continued to find this area needed improvement. Care plan audits were being completed, and the registered manager told us they had instructed staff to work on personalising care plans, however we continued to find areas where care plans required additional detail.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Accidents and incidents were monitored to ensure lessons could be learnt, if required, to reduce risk. Trends and patterns were analysed by the management team. People told us they felt safe at the home.

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.

The management team demonstrated enthusiasm to ensure learning and improvement at the home. However, there were some areas of improvement which had not been identified in the current system of management audits. Some care plan details and risk assessments required further attention to fully reflect people’s needs.