Ryedale Homecare

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 provider was previously in breach of the legal regulation in relation to governance. Enough improvements were not found at this assessment, and the provider remained in breach of this regulation.

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 did not always demonstrate a clear shared vision, strategy or culture that supported safe, high‑quality care. Leadership had not embedded structured governance systems, and the service remained heavily reliant on informal staff communication rather than clear organisational processes. The registered manager acknowledged a lack of auditing and oversight, and there was no action plan in place to implement required improvements identified at previous assessments.

Repeated shortfalls in governance and record‑keeping from earlier assessments had not been addressed. This indicated the provider did not fully understand or act on the challenges facing the service, nor embed a culture of continuous improvement.

Overall, although staff interactions with people were caring and positive, these strengths were not supported by a consistent organisational culture focused on learning, accountability and improvement.

People and relatives described the registered manager positively. However, operational leadership did not consistently translate into effective management including governance of the service.

The registered manager acknowledged significant gaps in governance. This included an absence of structured audits, delayed care planning, and limited oversight of daily records, risk assessments and competency checks. Several care plans and risk assessments were only completed or updated following CQC feedback, indicating a failure to effectively ensure timely or consistently delivered improvements.

Leadership demonstrated positive interpersonal qualities but lacked the systems, oversight and consistency required to ensure safe, well‑led care.

There was no evidence from the notes reviewed to suggest staff were unable to speak up or raise concerns. Staff had completed training related to harassment, bullying and equality through the employee assistance programme (EAP), supporting an open and respectful workplace culture. However, due to limited formal oversight systems, it was unclear whether information raised by staff was routinely captured, escalated or used to support organisational learning.Based on available evidence, staff appeared comfortable discussing concerns with the registered manager, but structured mechanisms for raising and analysing concerns were not always evident.

Staff received training in disability awareness, autism awareness and equality‑related topics, including harassment and bullying, which supported inclusive practice and awareness of protected characteristics.

The service demonstrated willingness to make reasonable adjustments for people with sensory needs, communication differences or learning disabilities, which supports an inclusive culture.

There was no evidence of discriminatory practice. However, governance gaps meant the provider did not always ensure equality‑related needs were recorded consistently in care planning.

The provider did not have effective systems of governance, oversight or record‑keeping. Major recurring issues identified in 2021 and 2022 CQC assessments, (including incomplete records, unmanaged risks, ineffective audits and failure to embed learning), remained unresolved. The service therefore continued to be in breach of governance requirements.

Evidence from our onsite assessment showed environmental home risk assessments had not been completed for any person at the start of the assessment, despite this being a known issue from previous assessments. Daily care logs had not been routinely reviewed, potentially preventing the manager from identifying changes in need or emerging concerns. Several people only had initial assessments of their care and support needs, with no care plans or risk assessments until prompted by CQC, confirming that improvements were reactive rather than embedded. Competency checks beyond medicines had not been completed, and the provider was still searching for templates to establish these systems. These findings demonstrated that governance was not effective, not embedded, and not sustainable, and had failed to improve despite repeated regulatory intervention.

The manager reported appropriate working relationships with external professionals, including social workers and learning disability teams, especially for people with a learning disability or autistic people. The service used hospital passports and worked with external agencies during hospital admissions, showing positive examples of partnership working where specific needs were identified. However, consistent evidence of broader community engagement or structured partnership working beyond care planning was limited in the available records.

Learning and improvement were not embedded into the service. There was no evidence of systematic auditing, and risks raised at previous assessments remained unaddressed. The provider did not demonstrate that feedback, incidents or daily records were used to drive improvement. Care planning and risk assessment activity only improved after we raised concerns, confirming that learning was reactive, not proactive.

While staff had completed relevant training (such as autism awareness, disability awareness and pain assessment tools), this learning was not consistently applied across the service due to gaps in care planning and governance.