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Yarrow Housing Limited - 1-2 Elmfield Way Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 12 December 2017

This inspection was carried out on 31 August, 7 September and 9 October 2017. The first day of the inspection was unannounced and we informed the registered manager of our intention to return on the second day. Following these two inspection visits we received information of concern from health and social care professionals in relation to the quality of care and support provided to people who used the service. The third day of this inspection was unannounced and was scheduled in order to gather further evidence. At our previous inspection on 14 and 16 July 2015 the service was rated ‘Good’. At this inspection we have rated the service as ‘Requires Improvement.’

1-2 Elmfield Way is a six bedded care home for men and women with a learning disability or autistic spectrum disorder. It is a bungalow with single occupancy bedrooms, a combined dining and lounge area, a small sitting room and a rear garden. None of the bedrooms are en-suite; there are shared toilets and bathrooms in the communal areas. At the time of this inspection there were four people living at the service.

There was a registered manager in post, who had managed the service for several years. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was present at the inspection.

The systems in place to identify and manage risks to people’s safety and wellbeing were not sufficiently rigorous. Staff understood how to protect people from the risks of abuse and how to report any concerns about people’s safety and welfare.

There were sufficient staff deployed to support people with their personal care and their preferred activities at home and in the wider community. Thorough recruitment practices were followed by the provider to ensure that people were supported by staff with appropriate experience and knowledge.

The premises were being safely maintained in regards to areas such as fire safety and the professional maintenance and servicing of equipment and installations. Medicines were managed in a safe way and staff received medicines training.

Health and social care professionals told us that people were not always supported to meet their needs. We found that some staff had experienced difficulties in completing monitoring charts required by external professionals.

Staff received ongoing training, one to one formal supervision and an annual appraisal of their performance. Staff received mandatory training, such as moving and handling people and fire safety. Training was being provided to enable staff to effectively support people by providing positive behaviour support.

Staff had received training about the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS), and they understood how to protect people’s rights.

Processes were in place to support people to meet their nutritional needs and to report concerns to relevant professionals if people needed more intensive support.

There were positive interactions observed between people who use the service and staff. People were treated with respect and their privacy was protected when they received personal care.

We received some negative comments about how people were supported to engage in meaningful activities. During the inspection we saw that people were actively using community resources and returned home pleased with their visits to places and activities of their choice.

Systems had been established to enable people and their supporters to make a complaint.

People were provided with a pictorial complaints leaflet and other more detailed pictorial materials were used to help people express their concerns and views.

Staff told us they felt well supported by the registered manager. H

Inspection areas


Requires improvement

Updated 12 December 2017

The service was not always safe.

Risks to people’s safety, health and well-being were not always identified and managed appropriately.

Staff understood how to identify and respond to signs of different types of abuse, and keep people safe from harm.

Staff were effectively recruited and deployed in suitable numbers to meet people’s needs.

Medicines were safely managed.


Requires improvement

Updated 12 December 2017

The service was not always effective.

Up to date information about people’s health care needs was not always recorded. Staff did not always follow guidelines from health care professionals.

Staff received training, supervision and support to carry out their roles, although additional training was needed by some staff to complete specific monitoring charts for people.

Staff understood about Deprivation of Liberty Safeguards and the Mental Capacity Act 2005. This meant they could take the appropriate actions to ensure people’s rights were protected.

People were supported to receive a balanced diet that reflected their preferences.



Updated 12 December 2017

The service was caring.

We observed positive interactions between people and staff. Staff supported people to maintain contact with relatives and friends.

Staff respected people’s privacy and dignity.

People were provided with accessible information about their rights.


Requires improvement

Updated 12 December 2017

The service was not always responsive.

Care and support plans did not always reflect people’s current needs.

Mixed views were gathered in regards to whether the service provided care and support that was responsive to people’s needs, wishes and interests.

Systems were in place to respond to any complaints in a professional way.


Requires improvement

Updated 12 December 2017

The service was not always well-led.

Health and social care professionals reported that there were deficits in the quality of care and support provided to people who use the service.

Staff told us they felt well supported by the registered manager.

Arrangements to monitor the quality of the service were not sufficiently rigorous.