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 changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of the legal regulations relating to safe care and treatment, good governance and staffing. This included concerns regarding risk management, infection prevention and control, medicines management and staffing levels.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

A learning culture was not embedded at the service. Repeated breaches of regulations and recurring concerns identified over time indicated that learning from previous assessments and regulatory action had not been effective in achieving and sustaining compliance or preventing similar issues from reoccurring.

Staff were knowledgeable about what to do in the event of an accident or incident and recorded them accordingly. Although the provider had a system in place to learn from accident and incidents, they did not use a holistic approach of learning to improve the service. This meant risks to people were not identified and addressed leaving them at continued risk of harm.

People did not always receive timely referrals to relevant healthcare professionals when concerns were identified. For example, concerns about people’s unintentional weight loss had not resulted in appropriate referrals by staff to dietetic services until we raised this during the assessment. This placed people at risk of not receiving the specialist support they required.

The provider had not ensured information needed to support effective partnership working was complete, accurate and consistently shared. For example, behaviour monitoring charts used to support healthcare professionals' assessments were not always completed and lacked sufficient detail. This meant professionals may not have had access to the information required to accurately assess people's needs and plan appropriate care.

When we shared these concerns with the provider, they told us information received from referring professionals was not always accurate. However, we found the provider had not always ensured information recorded and shared by the service was complete, detailed and up to date.

People were not protected from the risk of abuse, neglect and harm. Records showed people's basic care needs were not consistently met, including support with eating and drinking, repositioning, personal care and oral hygiene. Despite this, staff and managers had not recognised these concerns as potential neglect or taken appropriate safeguarding action which demonstrated ineffective safeguarding systems and oversight. We therefore raised a safeguarding concern with the local authority during the assessment.

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 and 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.

Risks to people’s safety and wellbeing were not consistently identified, assessed or managed. For example, a significant number of people had experienced weight loss. However, one person’s weight loss had not been identified, and no action had been taken to manage this risk. We also found several people had not been referred to dietitians despite having weight loss and being at risk of malnutrition, which meant risks to people’s wellbeing remained.

People remained at risk of skin damage as care was not delivered in line with their care plans. We found people with reduced mobility and at risk of developing pressure areas were not supported with regular positional changes. Records showed significant time intervals between repositioning and staff told us care was delivered late due to staffing levels in the service.

Fire safety risks were not appropriately managed. We found 2 people had recently moved into the home. However, personal emergency evacuation plans (PEEPs) for them had not been put into the emergency grab bag. This meant in the event in an emergency, staff and emergency personnel did not have up to date information to work from. This placed people, staff and emergency personnel at risk in the event of a fire.

The provider failed to ensure the safety of the environment and all equipment. At the last inspection, we found radiator pipes which could become hot were uncovered and raised this with the provider. At this assessment, we found sufficient action had not been taken and some pipes which could become hot remained uncovered. This meant people remained at risk of burns from coming into contact with uncovered hot surfaces.

Safety checks of equipment were not always appropriately completed. We found servicing for a hoist was 6 months out of date. This meant the provider could not be assured it was safe for people and staff to use which placed them at avoidable risk of harm.

The provider failed to ensure there were enough staff with the right skills to meet people’s needs safely and in a timely manner. At the last assessment we found staffing levels were unsafe and at this assessment we found they had deteriorated further. Care staffing levels remained the same despite more people using the service and people having more intensive and complex needs. Care staff were also required to carry out meal preparation, laundry and domestic tasks which took them away from their caring roles.

People and relatives discussed the issues with staffing levels at the home and the impact on them. People said, “[Staff] are fantastic, but there's not enough of them. If I ring, sometimes it’s 10-15 minutes before they come, other times it’s about an hour that I’m waiting” and “Sometimes you wait a long time, but that's because they're busy. Just after teatime is the worst.” Relatives also told us their loved ones had to wait for staff as they were busy, and people could benefit from having extra staff on shift. Staff consistently told us there were not enough staff.

Staff had not received appropriate training in texture-modified diets. For example, several people required food and drinks preparing to different textures to help manage risks associated with aspiration and choking. However, kitchen and care staff were not trained in preparing diets in line with professional advice. This meant food and fluids were not prepared in line with people’s care plans which increased their risk of aspiration and choking.

Staff did not always receive support and supervision in line with the provider’s policy. Records showed not all staff received supervision every 2 months. This meant there was little oversight of their skills, knowledge and any issues they may be having.

Recruitment and induction processes required improving to ensure only appropriate staff were recruited. Records did not show gaps in employment history had been fully explored and interview questions did not always check the skills and knowledge of potential staff to determine if they were suitable for the role.

Infection Prevention and Control (IPC) risks were not identified or responded to in a timely manner. During the assessment, we found there was an infection outbreak which had been active for several days. However, most staff had failed to identify the outbreak and raise their concerns with the registered manager. This meant IPC measures had not been promptly implemented and placed people, staff and visitors to the service at risk of contracting an infection.

The provider did not ensure that people’s medicines were stored and managed safely, and that they were administered as prescribed. We found medicines prescribed for people were not stored securely. This placed people at risk of their medicines being removed, tampered with or ingested by other people.

People’s medicines were not administered as prescribed. For example, one person was prescribed medicine to manage their diabetes and required food to be provided with or shortly after their medicine was administered. We found they regularly had their medicine; however, food was not always provided soon after. This placed the person at risk of developing health complications associated with their diabetes.

People were at risk of being unnecessarily restricted through the inappropriate use of medicines as protocols for the administration of ‘as and when required’ medicines were not consistently followed. For example, one person was prescribed medicine to be administered when they showed signs of distress and after non-medical interventions had been tried. However, records showed at times they were administered their medicine despite not showing signs of distress. This placed the person at risk of receiving medicine that may not have been required.