Yearsley Villa

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment, the rating has changed to requires improvement.This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment and medication.

This service scored 50 (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 always have a positive or effective culture of safety. Systems to investigate and learn from incidents were not consistently used. While accidents and incidents were recorded, there was limited evidence of learning or changes made to reduce the risk of recurrence. Records did not clearly describe how lessons were learnt. This meant opportunities to improve safety were missed and placed people at increased risk of harm.

The provider worked with people and partner organisations to maintain safe systems of care. The provider monitored people’s health and made appropriate health referrals when concerns arose. Information was shared with external professionals to support continuity of care, including when people moved between services. The provider understood when to escalate concerns to other care professionals to ensure people received appropriate care in a timely way.

The provider did not always ensure people were protected from abuse and avoidable harm. Safeguarding processes were not consistently followed or maintained. Although the registered manager understood how to raise concerns, oversight systems were not effective in ensuring safeguarding measures were implemented when needed. For example, after an incident, appropriate safeguarding procedure had not been followed so these events were not reported to the appropriate authorities, this included the local safeguarding team and CQC. Due to this we could not be assured that people would be appropriately safeguarded from potential abuse. The provider acknowledged this feedback on board during the inspection and planned to improve their records to help evidence how people were protected from abuse.

The provider did not consistently involve people in understanding or managing risks. Risk assessments were missing in key areas, for example, people who were at risk of financial abuse did not have a risk assessment in place. Where risk assessments had been developed these often-lacked sufficient detail to evidence how the risk had been mitigated safely. Care plans did not always reflect current risks, and clear guidance on how to manage people’s health and wellbeing was unclear. For example, the use of medical equipment had not been risk assessed and it had not been considered that the person may now be of increased risk of health deterioration due to the use of this equipment. After incidents, care plans were not updated, and risk assessments were not completed to show how the provider would reduce the risk of recurrence or minimise risks to the person, and others, if similar incidents happened again. Although there was no evidence that individuals were harmed because of these issues, the inconsistent way in which risks were managed by the provider increased the potential risk to people. Consequently, a breach of regulation was determined.

The provider maintained a safe environment for people. Checks were in place to identify and address environmental risks, and any maintenance issues were addressed without delay. People told us they felt their home was safe. People’s rooms were personalised to suit their tastes, needs, and preferences.

The provider did not always ensure they could evidence safe and effective staffing. Staffing was appropriate to meet the needs of the people. However, key areas of training was out of date which had not been followed up by the registered manager. For example, training in areas such as bipolar disorder, mental capacity and DoLs were last recorded as complete in 2023. The provider was not meeting the legal requirements to ensure all staff had the appropriate training in relation to learning disability and autism awareness. There was one additional member of staff who supported the service on a ‘as required’ basis. However, the provider had not implemented safe recruitment practices for this person, and they had not followed their own policy in this area. Due to these concerns relating to the providers governance and records we have followed this up within the well led domain.

The provider managed the risk of infection and took steps to prevent its spread. The service was clean and tidy with daily cleaning taking place. The provider knows how and when to use personal protective equipment (PPE) appropriately.

The provider did not ensure medicines were always managed safely. Risk assessments had not been developed for people who managed their own medication and there were no risk assessments to help ensure the safe storage of people’s medication. The providers own policy stated they would document a person’s ability to self-medicate and verify the medication administration via stock checks. However, this was not taking pace. The provider did not have a system in place to help evidence people were taking their medication correctly even though they told us they observed people taking their medication, records did not reflect this.People who required ‘as and when required’ (PRN) medicines did not have protocols in place to ensure this medication use was safely managed. During the inspection, the provider was accepting of the feedback provided and planned to implement new systems to help evidence safe medication management.