Terry Yorath House

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 reported safety events and lessons were learnt to continually identify and embed good practice.

Relatives consistently reported that concerns were responded to promptly, escalated appropriately, and followed up by managers. One relative told us, “If you speak to the manager he fixes issues straight away. He will always be honest, if he doesn't get something right then he will say so.”

Staff confirmed that issues were routinely discussed in monthly meetings, handovers, and supervisions, with one noting, “We improve practice on a daily basis through handovers, supervisions and team meetings.” The registered manager completed a monthly report for the senior management team and all concerns regarding the service were discussed.

During the assessment, we identified some incidents that although recorded the registered manager had not been alerted , timely action was taken to address this with learning clearly communicated to staff and integrated into service improvement plans.

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.

People’s needs were thoroughly assessed prior to admission to ensure the service could meet them safely and effectively. Some people were admitted as an emergency. Information was gathered following calls with social workers and peoples’ needs were assessed when they arrived at the service. Care documentation of one person admitted as an emergency contained evidence that family were involved with the admission.

Staff were guided by detailed care plans that brought together comprehensive information on individuals’ physical and mental health, communication needs, and daily support. They worked closely with the local GP and community nursing teams and demonstrated clear understanding of when to seek specialist input.

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.

Care staff completed safeguarding training and demonstrated a clear understanding of how to report concerns both within the service and to external agencies. Staff provided assurance that they fully understood the safeguarding process and their role in maintaining people’s safety.

Safeguarding policies offered clear guidance on when concerns should be raised with local authorities, and records showed that appropriate referrals and follow-up actions were taken where risks were identified.

However, a gap in the reporting process was identified, where some concerns had not been escalated to the registered manager for review and decision-making. The registered manager took immediate steps to address this.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In Care Homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that people had been referred to outside professionals for various medical needs and the provider was following these up.

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.

Risk assessments were person-centred, recognising individuals’ strengths, what they could do independently, and where they required staff support, such as with mobility. Care plans clearly outlined early warning signs and provided guidance for staff on how to deliver personal care in a way and at a time that suited the people living at the home. This included explaining the support being offered, adapting their approach, and adjusting the timing of interventions. Staff demonstrated good skills in recognising when people were experiencing pain and understood how this could affect their willingness to take part in activities, including personal care. It was identified that a person living in the service had bedrails in situ but did not have a risk assessment in place for this use. The registered manager responded promptly and took appropriate action to address the issues, strengthening oversight moving forward.

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

We reviewed records of checks carried out to ensure the premises were safe, including gas, electrical and fire safety checks. Regular equipment checks were also completed. Personal Emergency Evacuation Plans (PEEPs) were in place and regularly reviewed to reflect peoples support needs in the event of an emergency evacuation.

The main communal area was large and spacious and ideal for people who used large, motorised wheelchairs. We found that the electric wheelchairs did cause some damage to areas of the environment. The manager was aware of this and informed us that redecoration was part of the homes ongoing maintenance improvement programme.

There was a secure garden area surrounding the home. However, the registered manager acknowledged that certain areas within the garden presented potential risks to people using the service. These included uneven ground and paving stones, which could pose a trip hazard.

These concerns, along with others, were highlighted to the manager during the inspection. At our subsequent visit, we found that appropriate steps had been taken to address these issues, demonstrating a responsive approach to risk management and continuous improvement.

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.

People living at the service raised no concerns about staffing levels. They told us, “People come and assist quickly in the night staff go above and beyond,” and, “Staff are fantastic all of them, some are better than others, but they are all good.” People’s relatives told us they felt there were enough staff on duty to meet peoples’ needs. They told us that they felt staff were responsive to call bells when people needed assistance.

The service used a dependency tool to calculate staffing levels based on the needs of people living there. The staff rota reflected the dependency tool. Most of the staff we spoke with told us they felt staffing levels were appropriate.

Safe recruitment procedures were followed. A supervision and appraisal matrix was in place, and records showed staff had regular meetings. Staff completed an induction period when they first joined the service and confirmed they received the training required to carry out their duties. Training completion was monitored, and staff described a combination of online and face-to-face learning methods

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 manager told us that following a recent staffing review, the part-time domestic role had been discontinued. Cleaning responsibilities were now undertaken by care staff and allocated across all shifts. We found no evidence that this change had any impact on the care provision to people living in the home.

Relatives told us they were satisfied with the cleanliness of the home. During walkarounds on both site visits, we found the home to be clean and tidy throughout.

Staff had completed infection prevention and control training. We saw evidence that staff competencies had been assessed, including correct handwashing techniques and the safe application and removal of personal protective equipment (PPE).

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

People were supported to take their medicines at the appropriate times; with the level of support they required. Staff responsible for administering medicines had received appropriate medicines training, and the management team had completed competency assessments with staff involved in medicines administration. Staff spoken with confirmed this did take place.

PRN (as required) medicines protocols were available; however, these did not always contain sufficient detail to ensure safe and consistent administration. For example, one person prescribed a medicine had conflicting instructions across documentation. Although no harm had been caused this inconsistency created a risk of incorrect dosing or missed medication.

Staff did not consistently record the rationale for administering PRN medicines or the outcomes following administration. This lack of documentation limited the ability to evaluate effectiveness and ensure appropriate use.Additionally, some controlled drugs that were no longer required had not been labelled that they were no longer in use, therefore there was the potential that they could be administered. This was fed back to the Registered manager who took action.