Yarborough House RCH

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 good governance. Improvements were not found at this assessment, and the provider remained in breach of this regulation.

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’s vision and values were not modelled in day-to-day practice. There was no clear leadership driving a shared purpose and therefore practices did not support high-quality, compassionate care. During the visit, there was little sense of warmth or atmosphere within the service and people lacked meaningful engagement. Opportunities for stimulation and occupation were limited, and there was an overall lack of activities to promote people’s independence, enjoyment or social connection.

Staff worked hard to give their best to people but were exhausted by their roles. Staff appeared task‑focused and often too busy to spend time talking with people or show genuine interest in their wellbeing. This resulted in interactions that were functional rather than person‑centred and apathy amongst staff which suggested this culture had become embedded over time.

The management team did not always have the required skills or knowledge to improve the service. The registered manager had been in post for a long time, but they had been unable to improve the quality of the service. A deputy manager was in place and had been supported to develop their skills and knowledge through working closely with the registered manager. Following the assessment, the provider informed us the management team was changing, and the deputy manager would be submitting their application to register. The deputy manager was proactive in addressing shortfalls found, though further support was required to ensure they had the required skills and knowledge to identify and address shortfalls.

The management team were a visible presence in the service and supported staff to help lighten their workload. A person said, “The manager and deputy manager deliver care, so we get to know them, and they know us as well which is nice.” Staff told us how the management team supported them when they needed assistance.

The management team fostered a positive culture where people felt they could speak up, and their voice would be heard. A whistleblowing policy was in place and understood by staff. Staff told us they were confident raising any concerns as where concerns had been raised, they had been fully acted upon.

The provider and management team valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Where any discriminatory behaviour occurred, the management team acted to address it and supported staff.

The provider did not have clear and effective systems of good governance. Governance systems were in place, but they were not always robust or effective at finding shortfalls. For example, a range of medication audits were in place, though none had identified the issues we found.

Quality assurance systems which were in place, were not accurately completed. A recent premises audit had not been effectively completed and did not find the shortfalls we found with uncovered hot surfaces being accessible to people.

The provider’s quality assurance systems were not always operated in line with the provider’s schedule. Care plans were due to be audited every 6 months, though the last 2 audits had not been completed. Therefore, they were unable to identify the lack of details in people’s care plans.

Although the provider was trying to improve governance systems within the service, the tools they used had not identified the shortfalls we found within governance systems. The provider’s good governance audit did not review the quality of the audits or consider if they were effective at finding quality shortfalls and it was not completed regularly. This meant the provider was unable to identify and address quality shortfalls and improve the overall quality of the service.

The management team understood their duty to collaborate and work in partnership, so services worked seamlessly for people and people received the support they needed. They shared information and learning with partners and collaborated for improvement. The management team were also working with a local primary school so everyone at the service would receive a Christmas card from a local child.

The management team strived to learn from incidents to continually improve the service. Accidents and incidents were reported, investigated and changes made to reduce the risk of them happening again. Staff were kept informed of lessons learned through staff handovers.