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 changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider was in breach of the legal regulation in relation to governance of the service.

This service scored 36 (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 not created a culture that prioritised high-quality care and positive outcomes for people. Staff told us they were committed to providing good care and shared values centred on supporting people's wellbeing, dignity and independence. However, the provider had not responded effectively to concerns about staffing levels and had not recruited to vacant posts.

Staff described being expected to meet people's needs with insufficient resources and increasing demands. As a result, people's care was not always delivered as planned and opportunities for meaningful engagement and social interaction were reduced. The concerns identified during the assessment demonstrated a disconnect between the values held by staff and the culture promoted by the provider.

Leaders did not have the capacity, skills, knowledge or resources required to lead the service effectively. Whilst the registered manager was committed to improving the service and was viewed positively by staff, they had not been adequately supported by the provider to address ongoing concerns within the service.

The provider had failed to ensure there was sufficient management capacity to oversee the service. Following the promotion of the deputy manager to registered manager, the vacant deputy manager post had not been filled, leaving the registered manager responsible for both roles. This significantly reduced leadership capacity and limited effective oversight of the service.

Despite previous assessments, regulatory action and repeated concerns being identified, the provider had failed to achieve sustained improvements. Shortfalls in staffing, care delivery, risk management, governance and safeguarding remained evident. This demonstrated leaders had not ensured people received safe, high-quality care and support. As a result, the quality of the service had continued to deteriorate, and people remained exposed to poor outcomes and avoidable risks.

The provider did not have effective systems to ensure concerns raised by staff were listened to, acted upon and used to improve the safety and quality of the service. A whistleblowing policy was in place and staff told us they could raise concerns to the registered manager, and they would be acted upon. However, where staff had raised concerns around staffing levels, they had not been addressed by the provider which continued to place people at risk of harm.

Whilst the provider promoted equality, diversity and inclusion within the workforce and staff had received equality and diversity training, staff feedback about their experiences was mixed. Some staff told us there was respect for different cultures and backgrounds and that staff were treated equally. However, others felt there were inconsistencies in how concerns were managed and did not always feel staff in different roles were treated fairly.

The provider failed to implement and have appropriate systems in place to maintain the safety and the quality of the service. This meant shortfalls we identified with the environment, risk management, care delivery, food provision, medicines and staffing levels had not been identified or acted upon which placed people at continued risk of harm and receiving a poor-quality service.

The provider did not always work effectively with partners to improve the service. Referrals were not always made for people when needed and professional advice was not always followed. There had also been ongoing involvement from the local authority since the last assessment, and an action plan was in place. However, the provider had not ensured timely and sustained improvements. This demonstrated the provider had failed to effectively use external oversight, support and feedback to drive improvement, and the quality of the service had continued to deteriorate.

The provider did not demonstrate a culture of continuous learning and improvement. Repeated concerns identified through previous assessments and regulatory action remained evident, indicating lessons had not been learned, and improvements had not been sustained. As a result, people continued to experience inconsistent care and poor outcomes.