Yohden Hall Care Complex

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 requires improvement. At this assessment the rating has remained 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 governance at the service.

This service scored 62 (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 proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

There had been an issue with the safety and condition of the premises that had been first identified in 2022 which had not been addressed at the time of this assessment. This has been highlighted as a concern to the provider on numerous occasions but limited had been taken to address the issue and safety concerns remained.

Staff listened to concerns about safety and investigated and reported safety events. For example, accidents and incidents were regularly discussed at meetings to see if practice could be improved to keep people safe.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. They made sure there was continuity of care, including when people moved between different services. People had access to health and social care professionals. We saw healthcare partner visits in place to support people when needed. Care plans contained “about me” documents, created with people and their families as well as life stories, preferences, likes, and wishes. Information about people’s individual needs and risks they might face were in place, and people and relatives had been involved in writing these.

People were safeguarded from abuse. 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. Staff received safeguarding training and said they would not hesitate to report any concerns they had.

The provider worked with people to understand and manage risks by thinking holistically. Risks to people’s health and safety were assessed using a number of recognised risk assessments, such as Waterlow for skin integrity. Risk assessments provided good guidance to staff on how to mitigate risks to people. These were continually reviewed and amendments made to care practices where change was required. Positive behaviour support plans were in place to guide staff on how to support people through heightened levels of anxiety. These documents included what could be a trigger for people, how they would present if they were highly anxious, and distraction techniques staff could use to calm them.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. The roof of the premises had been leaking for a number of years, which had been identified on previous action plans but not addressed when we visited. In some communal areas and corridors roof tiles were missing, and buckets were in place to catch dripping water. This placed people at risk when mobilising around the home. There were visible water marks on items such as carpets. When discussing how long the roof had been leaking one member of staff said, “Looking at at least 3 years, at least. That's when it became a major situation.”

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 supported by regular training, supervision and appraisal and spoke positively about this. One member of staff said, “These are done correctly and within a timely manner and always done professionally.” Staffing levels were monitored to ensure people received safe and effective support. One person told us, “There’s always plenty of staff around.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. At our last assessment we found issues with IPC practice relating to COVID-19 practice. Improvements were made and sustained following feedback from that visit. However, at this assessment we found an ongoing issue relating to a leaking roof and the management of the environment. In some cases this had caused visible water damage, which prevented effective cleaning. Some areas were also in need of further cleaning, such as a carpet near a dining room and an extractor fan in a shower room.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. At our last assessment we found issues with medicines management practice relating to the storage of medicines. Improvements were made and sustained following feedback from that visit. At this assessment we saw medicines were stored safely and securely. Clear records of medicines administration were kept, and care plansincluded information around people’s medicines support needs.