Urgent improvements are needed at York House, Lincoln, after CQC rating drops from good to inadequate

Published: 30 March 2022 Page last updated: 12 May 2022

The Care Quality Commission (CQC) has told York House in Lincoln, to make urgent improvements and placed it in special measures following an unannounced inspection in January.

This inspection was carried out following concerns received about their infection, prevention and control measures. Due to further issues being found during the inspection, inspectors also looked at how safe and well-led the service was.

Following this inspection York House has been rated inadequate overall and for being safe and well-led. It was previously rated good in 2018.

York House, run by LJ Care Homes Ltd, is a residential care home and domiciliary homecare service providing accommodation and personal care primarily for older aged adults including those living with dementia. This inspection looked at the residential care home service being provided. At the time of inspection, 16 people were living there.

Natalie Reed, CQC head of inspection for adult social care said:

“When we inspected York House, we found a care home that wasn’t well-led. The management team failed to ensure systems and processes were in place for staff to provide quality, safe, person-centred care. Also, there wasn’t an adequate system for people to feedback on care their loved one was receiving to help the service make improvements.

“People were at risk of harm due to poor infection prevention and control practices. We found people with COVID-19 didn’t have notices on their doors and were not being regularly identified on handovers, so staff were not always aware who had COVID-19 which could have resulted in other people contracting it and becoming ill. PPE was not always worn, there was not a robust cleaning process in place and staff didn’t have the required knowledge to sufficiently control infection at the service.

“It was worrying that people weren’t always protected from the risk of abuse. Staff told us people had become distressed due to alleged abuse at the service, they hadn’t reported these concerns to the local authority, so they weren’t investigated. Some staff members told us they haven’t received any safeguarding training and didn’t feel comfortable raising safeguarding concerns to the management team due to potential repercussions, which is completely unacceptable.

“The leaders of York House now understand where further improvements must be made and have started to address our concerns. We will continue to monitor the service and if improvements are not made, we will not hesitate to take further action.”

Inspectors found the following:

  • The provider failed to ensure that effective governance systems were in place
  • Systems to ensure the safety and quality of the service were not effective
  • People were not safeguarded from the risks of abuse
  • Risks to people 's health, safety and welfare were not always identified or managed effectively, and care plans were not always in place
  • Their approach to visiting did not always align with government guidance
  • Medicines were not always managed and stored safely, and people did not always receive medicines as prescribed
  • There were insufficient measures in place to reduce the risk of infection spreading
  • We did not find evidence of lessons being learnt following accidents and incidents
  • Staffing levels at the service put people's safety at risk.


  • Despite the above concerns, people and relatives were overall positive about the safety of the service. People told us they knew to speak to staff if they needed to raise concerns
  • Staff members deployed were consistent and the service only used permanent staff
  • The service worked closely with the local GP surgery.

Full details of the inspection are given in the report published on our website.

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About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.