Yellow Rose Healthcare Limited

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 as requires improvement. At this assessment the rating has remained requires improvement. This meant the service 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 in breach of legal regulation in relation to good governance, display of ratings, notification of other incidents and statement of purpose.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider lacked oversight to ensure safe and effective governance was in place and that staff had clear responsibilities. The provider was not ensuring the service was being managed safely. For example, the provider’s governance arrangements had failed to identify shortfalls in how incidents, accidents and safeguarding concerns were logged, and actioned. This meant opportunities to improve the service and ensure people received safe and effective care were missed. Notifications had not been made to CQC as required and actions had also not been taken following an incident that had been raised as a safeguarding concern. The provider had not identified shortfalls in the recording of staff induction, training, and other employment information. This meant opportunities to identify areas of staff training and development that were needed were missed. Processes to ensure care plans were regularly reviewed were not effective. This meant there were missed opportunities to improve people’s care and staff knowledge. While people felt staff knew them well, we were not assured staff were always aware of the specific health needs of people they were supporting. Systems and processes were not effectively established to allow the provider to have oversight of concerns raised by people using the service and external partner agencies. For example, we found complaints from people using the service were not being logged along with actions taken the provider was not displaying their CQC assessment rating as required on their website. A copy of the previous inspection findings however was available in the office. Other documentation we would expect to see such as an up-to-date statement of purpose confirming the objectives of the service were not in place. We were therefore not assured the provider was fully aware of their responsibilities. Staff contact details were requested but not provided as part of this inspection. This meant we were unable to speak to staff.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.