Yarborough House RCH

Updated 17 May 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

One inspector carried out this inspection, and an Expert by Experience made telephone calls to people’s relatives. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Yarborough House RCH is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 15 March 2022 and ended on 23 March 2022. We visited the service on 15 March 2022.

What we did before inspection

We reviewed information we had received about the service. We sought feedback from the local authority. We used all this information to plan our inspection.

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

During the inspection

We spoke with the registered manager, deputy manager, two care workers and a housekeeper. We spoke with one person who used the service about their experience of the care provided. We spoke with five relatives via telephone. We reviewed a range of records. This included three people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We spoke with the fire service in relation to fire safety concerns.

Updated 17 May 2022

About the service

Yarbrough House RCH is a residential care home providing personal care to up to 25 people aged 65 and over, some of whom may be living with dementia. The service was supporting 20 people at the time of the inspection.

People’s experience of using this service and what we found

People had been placed at risk due to fire safety measures not being actioned in a timely manner and having insufficient staffing numbers to evacuate people in the event of a fire. Other areas of improvement including maintenance checks, health risks and decorating were identified. The provider took action to address urgent concerns we found during the inspection.

The provider lacked the appropriate systems and processes to drive forward improvements in a timely manner. The provider's own systems of oversight had not identified most concerns we found during the inspection.

People were supported by kind and caring staff. End of life care wishes were explored and recorded. We have made a recommendation about the management of complaints.

Visits to people were arranged in line with government guidance. We signposted the provider to resources to support their approach including the use of essential care givers.

Systems in place to monitor staffing levels were not effective and all relatives we spoke with said there were staff shortages at times. Prescribed medicines were managed safely however, improvements in the provision of as required medication was required.

Staff knew how to report allegations and concerns of abuse and understood their roles clearly and what was expected of them. Recruitment and selection processes were followed.

People were supported to have maximum choice and control of their lives and staff supported in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the Care Quality Commissions (CQC) website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 2 December 2020 under this provider and this was their first inspection.

Why we inspected

This was a planned inspection as a newly registered service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safety and provider oversight at this inspection.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.