Yews Hill / North Rise

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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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 a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Accidents, incidents and complaints were appropriately managed. Investigations were completed when required. Lessons learnt were identified and shared with staff to support practice development and service improvement.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider understood the importance of accurate information sharing to ensure people’s care was joined up and safe. Pre-admission assessments were completed prior to a person moving in to ensure their needs could be met. This process included meeting with the person face to face and the person visiting the service before any transition took place. The provider worked effectively in partnership with other professionals and services to safely support people.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Systems and processes were in place to ensure people were safeguarded from the risk of abuse. Safeguarding incidents were logged and appropriately reported to partner agencies, for example, the Local Authority and CQC. Staff received safeguarding training. People and relatives told us it was safe at the service. Comments included, “I am safe. Staff make me feel safe. They look after me” and “[The service] is safe.”

Where people were subject to Deprivation of Liberty safeguards (DoLS) the provider had made applications to the local authority and there was monitoring in place. DoLS ensure if a person is restricted in a way that deprives them of their liberty in a care home, it is only done when it is in their best interests, is necessary for their safety, and all other options have been considered.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care records were up to date and reflective of people’s current needs and risks. This enabled staff to support people safely. People and relatives were consistently involved in formulating and reviewing care plans and risk assessments. Feedback included, “I have seen my care plan. I'm involved. I feel like what is in there is right” and “They involve me in [Name]’s care plan and take on board my views.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Systems and processes were operated effectively to maintain a safe environment for people to live in. The environment was decorated nicely and in a good state of repair. One relative told us, “The home is nice and so is [Name]’s bedroom. It's well maintained.”

Appropriate health and safety processes, and equipment checks were in place. Personal emergency evacuation plans were up to date, accessible and reflective of people’s support needs in the event of a fire.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff were skilled and knew people very well. They worked effectively together to meet people’s needs, without delay and were proactive in their approach.

Staff participated in a wide range of training relevant to their role, including learning disability training. They also participated in supervision and annual appraisals to support their development. Safe recruitment processes were in place and new staff were supported via an induction process to introduce them safely into the service. One staff member told us, “I had a good induction and support.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean, tidy and odour free throughout. Domestic staff were observed cleaning throughout the day. They told us they had all the equipment and products they needed to maintain a high standard of cleanliness. A partner agency had recently completed an audit of the service and provided positive feedback regarding infection prevention and control.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines were stored securely in locked cupboards, with internal and external medicines appropriately segregated. There were no missed medicines identified on the day of assessment, and sufficient stock was available to support safe administration. However, some people who were prescribed medicines as regular doses were only receiving these on an ‘as and when required’ (PRN) basis. The manager advised these medicines had been changed to PRN; however, the medication administration records (MARs) had not been updated to reflect this. Further clarification was required with the GP to ensure prescriptions and associated records were accurate and up to date.

People who were prescribed PRN medicines did not always have up‑to‑date protocols in place to guide staff on how and when these medicines should be administered. Where people were prescribed variable doses, for example 1 or 2 tablets, there were no clear instructions to support staff decision‑making regarding the appropriate dose to administer or when to escalate concerns. Although some variable dosing instructions were recorded on MAR charts, this was not consistent for all people.

People who had their medicines administered covertly, concealed in food or drink, did not always have clear and comprehensive documentation from relevant healthcare professionals to support safe administration. Although some documentation was in place to show that GPs had reviewed people’s needs on a regular basis, the information provided lacked sufficient detail. The registered manager acknowledged this and agreed to seek additional written guidance from the GP and pharmacist to ensure staff were provided with clearer and more robust instructions to follow.

Liquid medicines did not have the date of opening recorded on their labels, which created a risk medicines could be administered beyond their once‑opened expiry date. Staff told us they had a positive working relationship with the supplying pharmacy and were able to obtain additional or urgent medicines when required, outside of the routine monthly delivery schedule.

Body maps were in place for people prescribed topical creams to support staff in applying these medicines correctly. However, although patch rotation charts were present, these had not been completed with dates and staff signatures. As a result, it was unclear whether patch rotation had been undertaken appropriately.

The registered manager was taking action to address the concerns found during the assessment in relation to medicines management and there had been no impact on people.