Yearsley Villa

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment, and support achieved good outcomes and promoted a good quality of life, based on best available evidence.At our last assessment we rated this key question good. At this assessment, the rating has changed to requires improvement.

This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The service was in breach of legal regulation in relation to consent to care and person-centred care.

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.

The provider did not assess people’s needs effectively or ensure these were comprehensively recorded and understood.Care plans lacked sufficient detail about people’s general and mental health, and personal care needs. For example, records did not describe how fluctuations in mental health affected people’s presentation, any triggers or the support required. Risk assessments were either absent or incomplete, including for behaviours, finances, and medication management. There was also conflicting and inconsistent information across care records, which meant staff could not rely on them to guide safe and effective care. Systems were not in place to ensure records were accurate, up to date or reflective of people’s current needs. This meant the provider could not demonstrate people’s needs were fully assessed or care was planned in line with their individual requirements.

The provider did not always ensure care and treatment were delivered in line with current evidence and best practice. Although, the provider could tell us how they knew people’s needs and could describe supporting people, using their knowledge and experience. However, documentation did not clearly evidence this. Records and processes did not align with recognised guidance. For example, medication practices did not follow expected standards and guidance. The provider was also not meeting the legal requirement for training in relation to 'learning disability and autism awareness'. We found shortfalls in the providers understanding of the Mental Capacity Act 2005 (MCA). Therefore, there was limited assurance that care and treatment was consistently delivered in line with evidence-based guidance.

The provider worked with external professionals and services to support people’s needs and continuity of care.The provider described regular contact with health professionals, including mental health teams. Records showed that other professionals were involved in supporting people when their needs changed.People were supported to attend healthcare appointments, and the provider demonstrated awareness of when to seek support from external agencies. For example, there was evidence of engagement with mental health services during periods when people’s mental health fluctuated.

The provider did not always support people to live healthier lives through structured monitoring and proactive care. People accessed healthcare services and were supported to attend appointments, including routine and specialist care. However, there was limited documentation to show how staff promoted or supported improved health outcomes, including managing risks associated with fluctuating mental health or long-term conditions. Care plans stated the provider was to offer support to maintain healthier lifestyles and promote independence but there was little evidence to demonstrate how this support was being provided.

The provider had some processes in place to monitor people’s wellbeing, but these were not consistently formalised or evidenced. The provider described monitoring people’s mental health and wellbeing and responding to changes, including contacting external professionals when required. However, there were no formal systems or audits in place to review outcomes or ensure continuous improvement. Records such as daily notes were not in place, and there was limited evidence of review following incidents or changes in need. This reduced the provider’s ability to evaluate care effectively and demonstrate how outcomes were improved over time. Despite these limitations, the provider’s knowledge of people helped to identify changes in their condition, which supported day-to-day outcomes.

The provider did not always ensure consent to care and treatment was obtained and recorded in line with legal requirements.While the provider described involving people in decisions and supporting their independence, formal assessments of capacity were either absent or not decision specific. Records did not consistently demonstrate how decisions had been made in line with the MCA. For example, there were no clear capacity assessments or best interest decisions in relation to areas such as finances or medication management.Where capacity had been assessed, documentation lacked clarity and did not demonstrate a structured or legally compliant approach.This meant we could not be assured that appropriate consent processes were consistently followed. Due to these concerns a breach of regulation was identified. The provider had taken steps to address these concerns following feedback during the inspection,. However, more time is needed to ensure sustained understanding and that records reflect the principles of the Mental Capacity Act 2005.