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CQC report explained · a residential care home

What the CQC found at Yaxley House

Goodpublished 6 March 2020, 6 years ago

Rated Good: inspectors found the home performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
Inspectors found that risks were assessed, staff understood safeguarding and there were enough staff to meet people's needs. Medicines, recruitment, cleanliness and learning from incidents were managed safely.
Effective?
Good
People's needs and choices were assessed before they moved in. Staff had relevant training, people received support with food and drink, and healthcare professionals were involved when needed.
Caring?
Good
People described staff as considerate and understanding. Inspectors saw positive relationships, and found that people were involved in decisions and treated with dignity and respect.
Responsive?
Good
Care plans reflected people's preferences, risks and personal histories. People had access to activities, communication support, visitors and a complaints process.
Well-led?
Good
People and relatives said the home was managed well. Managers used meetings, surveys, audits and discussions with staff and families to monitor and improve care.
The latest report, explained

What inspectors found, March 2020

Yaxley House is rated Good; inspectors found safe, kind and personalised care with effective management.

This was an unannounced planned inspection on 10 February 2020. Two inspectors spoke with four people living at the home, four relatives and staff. They also observed care and checked care plans, medicine records, complaints and quality checks.

The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines management, suitable training, clean premises and care plans that reflected people's needs and choices.

People told inspectors they felt safe and were treated with dignity and respect. Staff supported people with food, drink, activities, healthcare appointments and end of life care. The home had systems for handling complaints and checking the quality of care.

What inspectors praised
  • Safe staffing and medicines

    Inspectors found enough staff to meet people's needs, with staffing increased when people's needs changed. Medicines were administered, recorded and audited safely.

    “There were enough staff available to meet people's needs, and robust recruitment procedures were followed. Medicines were managed safely by staff who had received appropriate training.” from the report
  • Kind and respectful care

    People described caring relationships with staff. Inspectors saw staff responding promptly, offering reassurance and supporting people's independence.

    “People had developed meaningful and caring relationships with staff who they described as considerate and understanding.” from the report
  • Personalised support

    Care plans recorded people's preferences, risks and personal histories. People were offered choices about their routines, food and activities.

    “People's care plans reflected their care preferences, assessed risks, personal histories and reviews of the care plan.” from the report
  • Good activities and relationships

    People were supported to take part in activities they chose, spend time with others and keep in touch with family and friends.

    “People were supported to enjoy a wide range of activities and told us they had made friends with other people living at Yaxley House.” from the report
  • Quality checks and listening

    Managers used audits, meetings, surveys and a 'grumbles' book to identify issues and act on people's views.

    “The registered manager had established a process of service governance which included audits each month to learn how the service could be improved.” from the report
What inspectors were concerned about

Inspectors raised no specific concerns in this report.

Questions to ask them, based on this report
  1. 01How do you review care plans when a person's needs or risks change?
  2. 02How do you make sure staffing levels increase when people's needs fluctuate?
  3. 03What activities are available for someone with my relative's interests and communication needs?
  4. 04How are families involved in care reviews and decisions about end of life care?
  5. 05How are complaints and minor issues recorded, investigated and followed up?

This was an unannounced planned inspection covering all five CQC questions; all ratings remained Good from the previous inspection published on 21 July 2017. This explanation was written from the published report of 6 March 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

An earlier report, explained

What inspectors found, July 2017

Yaxley House: Rated Good; inspectors found kind, safe care, with improvements still needed in staffing, supervision and care planning.

The inspection was unannounced and took place on 12 June 2017. Inspectors observed care, spoke with people, staff and managers, reviewed four people's care records and checked staff and service records.

The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were protected from abuse, received their medicines, had access to healthcare and were treated with kindness and respect.

There had been improvements since the previous inspection. More staff had been recruited, including staff for laundry and activities. However, some staff and people said staffing could still feel tight. Records did not show that people had been involved in writing their care plans, and staff supervision was behind.

What inspectors praised
  • Safe recruitment

    The home checked applicants' backgrounds, references and suitability before they started work.

    “Safe recruitment procedures ensured that staff with the appropriate experience and character supported people.” from the report
  • Kind and respectful care

    Inspectors saw staff speak calmly, give people time and protect their privacy and dignity.

    “People were treated with kindness and compassion in their day-to-day care.” from the report
  • Healthcare support

    People could access health professionals when needed, and the home made referrals when people's needs changed.

    “When people's needs changed, the service made referrals to specialist services in order to ensure people were receiving the appropriate care.” from the report
  • Activities and choice

    People were supported with interests, social activities and community links. The home had recruited activities staff to improve this area.

    “People were supported to follow their interests and take part in social activities.” from the report
  • Quality monitoring

    Managers carried out regular checks covering areas such as medicines, accidents, complaints and care records.

    “Regular audits were completed by the manager and provider's representative to monitor service provision and to ensure the safety of people who lived in the service.” from the report
What inspectors were concerned about
  • Staffing could feel tight

    needs fixing

    Some people and staff said there were times when more staff were needed or people felt rushed. Inspectors saw timely care during the visit, and further staff were waiting for pre-employment checks.

    “Feedback from people about the number of staff was mixed with one person saying, "No there's not enough staff but I always feel safe when I am being helped,” from the report
  • Supervision was behind

    needs fixing

    Records did not show regular one-to-one meetings for staff to discuss their development and care quality. The manager said there was a plan to bring these up to date.

    “Records did not demonstrate that staff had received regular one to one supervision where they could discuss their development and the quality of care they provided.” from the report
  • People's involvement in care plans

    needs fixing

    People could describe the care they received, but no one spoken with recalled being involved in decisions about their care. Their records did not show that they had helped write them.

    “However, no one we spoke with could recall being involved in discussions or decisions about their care.” from the report
  • Manager not yet registered

    needs fixing

    The previous registered manager had left. A new manager was in post but was still completing checks before applying to become registered.

    “The service's registered manager had left the service prior to this inspection.” from the report
Questions to ask them, based on this report
  1. 01How many care staff are normally on duty on each shift, and what happens when staffing feels tight?
  2. 02Are all staff one-to-one supervision meetings now up to date?
  3. 03How will my relative be involved in writing and reviewing their care plan?
  4. 04Has the manager now applied to become the CQC-registered manager?
  5. 05What activities are available, and how are they matched to each person's interests and abilities?

This was an unannounced inspection covering all five CQC questions and the overall rating. This explanation was written from the published report of 21 July 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

The story over the years

Every inspection of Yaxley House

3 rated inspections over 3 years: the service has improved, from Requires improvement to Good.

  1. March 2020Goodcurrent ratingstayed Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read what inspectors found at Yaxley House →

  2. July 2017Goodup from Requires improvement
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read what inspectors found at Yaxley House →

  3. November 2016Requires improvement
    Safe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good

    Read this report on cqc.org.uk

  4. September 2014

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  5. December 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  6. September 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  7. April 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  8. December 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  9. September 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  10. March 2012

    Registered with the Care Quality Commission on 26 March 2012.

Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.

Next steps

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