Yarborough House RCH

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 provider was previously in breach of the legal regulation in relation to people’s safe care and treatment. Improvements were not found at this assessment, and the provider remained in breach of this regulation. We also found the service was in breach of legal regulation in relation to safe staffing at this assessment.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The management team operated a culture of safety through learning lessons from accidents and incidents. Staff appropriately responded to accidents and incidents, reported them accordingly and kept people’s relatives informed. The management team monitored and investigated accidents and incidents, sharing lessons learnt with staff to embed good practice and reduce the risk of them happening again.

The management team worked with people and healthcare partners to establish and maintain safe systems of care. They gathered and appropriately shared information about people’s needs when people moved into or out of the service.

The management team worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff protected people’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff had the skills and knowledge to identify safeguarding concerns which were appropriately reported to relevant professionals, and action taken to safeguard people.

People were safe and they told us they felt safe when staff were supporting them with their care needs. A relative said, “I know my parent is safe from any issues and they are vulnerable, but I trust the staff 100%.”

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care services this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA and whether proper legal authorisations were in place when needed to deprive a person of their liberty. People’s capacity was assessed, though records lacked detail about the questions people were asked and their responses. Applications were appropriately made to deprive people of their liberty, with records updated following authorisations. The management team monitored DoLS, to ensure new authorisations were applied for in a timely manner.

The management team did not work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people’s health and safety were not always identified or mitigated. For example, a food server and radiator pipes with hot surface temperatures were in the dining room. However, there was no risk mitigation in place to stop people touching these surfaces or falling against them which placed people at risk of burns. We raised this with the management team who ensured the issues were resolved promptly.

Where people were unsafe to leave the service on their own and they were at risk of trying to do so, this risk was not fully assessed and known by staff. One person was observed trying doors so they could leave the service. Staff were unaware of this person’s exit seeking behaviour and there was no risk assessment or care plan in place to guide staff in how to respond to these behaviours. The lack of risk assessment and risk mitigation placed people at risk of harm through absconding.

Personal Emergency Evacuation Plans (PEEPs) were in place to inform staff of the support people needed to evacuate the building in an emergency. Staff were trained in fire safety and regular fire drills were held to ensure staff had the skills and knowledge to support people in an emergency situation.

The provider ensured equipment, facilities and technology supported the delivery of safe care. The safety of the building and equipment was maintained through the completion of regular checks, maintenance, decoration and servicing.

The provider did not make sure there were enough care staff. People and their relatives told us there were not enough staff. People said, “The staff are very busy” and “Staff are busy, but it would be nice to have a chat and a cuppa sometimes.” Staff consistently told us there were not enough staff.

Systems were in place to identify required staffing levels. However, systems used were not robust and had not maintained safe staffing levels. The provider’s staffing tool did not consider the total number of people who needed support from 2 staff with personal care and positional changes and how this support often coincided with medicine rounds. This meant there were no staff available to meet people’s needs during these times. We saw communal areas were often unstaffed despite people regularly using these areas.

The management team assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff were trained in infection prevention and control, and isolation processes were followed in the event of an infection outbreak with Personal Protective Equipment (PPE) available. The service was clean and tidy. One person said, “The home is clean, warm, tidy and very welcoming.”

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

People’s medicines were not always administered as prescribed. One person was prescribed medicine to manage their stomach acid which needed to be administered 30 to 60 minutes before food. However, this medicine was regularly administered a long time after food. Another person was prescribed lorazepam to be administered ‘as and when needed’ (PRN) to help minimise behaviours that challenge others. Though, this medicine had not been administered in line with the person’s PRN protocol.

The provider’s policy for the covert administration of medicines was not followed. Advice had not been sought from the pharmacist. Therefore, there was no guidance in place for staff to follow to ensure medicines were only administered with suitable food or drink.

Risks associated with the use of emollients had not been assessed. There were no risk assessments in place which placed people at risk of injury from fire caused by unsafe use.

Processes for the return and disposal of medicines were not robust, and the provider’s policy had not been followed. The provider’s policy required all unused medicines to be returned to the pharmacy. However, we found medicines which had been dispensed but not administered had not been returned. Their storage was not in line with best practice guidance and there was no complete record of these medicines which meant the provider could not be assured all medicines were accounted for.

Staff engaged positively with people when administering their medicines and respected their right to refuse.