CQC report explained · a residential care home
What the CQC found at Yearsley Villa
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2018
Yearsley Villa was rated Good; inspectors found safe, caring and personalised support, with some records and training needing improvement.
This was a comprehensive inspection on 25 April 2018. One inspector spoke with all three residents, the registered providers, a relative and two social care professionals. The inspector also observed care and checked care plans, training records and quality records.
The home remained Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Residents said they felt safe and were happy with the care. Inspectors found medicines were managed safely, risks were assessed, and people received support that reflected their choices and needs.
Inspectors found warm and respectful relationships. Residents were supported to be independent, take part in activities and stay involved in their local community. Care plans were clear and personalised, and families and other professionals were involved.
There were some areas to improve. Some training was overdue, formal mental capacity records were missing, background checks had not been updated for some time, and some policies were overdue for review. These issues did not change the overall Good rating.
People felt safe
Residents said they felt safe, and inspectors found clear risk plans and safe medicines systems.
“People were protected from avoidable harm and risk management plans were in place which provided clear guidance about the support people required to stay safe and well.” from the report
Warm relationships
Inspectors saw caring relationships and found that people were treated with dignity, respect and compassion.
“All of the interactions we observed and the feedback we were provided by people, families and professionals showed the registered providers treated people with dignity, respect and compassion.” from the report
Personalised care
Care plans explained what mattered to each person, how they wanted to be supported and what they could do for themselves.
“They were clear, well written documents which gave the reader a sense of what was important to the person, how they liked to be supported and what they could do for themselves.” from the report
Support for independence
People were supported to make choices, use the home freely where appropriate and take part in activities they enjoyed.
“The registered providers supported people to be as independent as possible.” from the report
Background checks were not recent
minorThe required checks for the registered providers and occasional staff had not been updated for some time. The provider agreed to renew them more regularly.
“These had not been updated for some time.” from the report
Some training was overdue
needs fixingMedicines training and some other training needed refreshing. The provider agreed to complete the overdue training and improve records of when training should be renewed.
“We noted the training the registered providers had completed for medicines was overdue.” from the report
Mental capacity records
needs fixingInspectors saw people being involved in decisions, but formal records of mental capacity assessments and best interest decisions were missing.
“However, there was no formal mental capacity assessment or best interest decision record.” from the report
Policies needed review
minorSome policies were past their planned review dates. The provider agreed to review them.
“Some of these were overdue the review date which had been set by the registered provider but we did not see this affecting the outcomes for people living at the home.” from the report
- 01Which staff training was overdue at the inspection, and has all of it now been refreshed?
- 02Have the background checks for the registered providers and occasional staff been renewed?
- 03Have formal mental capacity assessments and best interest decisions now been recorded where needed?
- 04Which policies were overdue for review, and when were they last reviewed?
- 05How is care arranged if the registered providers are away or unable to provide support?
This was a comprehensive inspection covering all five key questions, and all five ratings remained Good. This explanation was written from the published report of 2 June 2018 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.
What inspectors found, January 2017
Yearsley Villa rated Good; inspectors found improved safety arrangements, with some detail still needed in one evacuation plan.
This was an announced focused inspection on 19 December 2016. Inspectors checked whether improvements had been made after a previous inspection found a breach involving fire safety, environmental risks and emergency arrangements.
The home had an up-to-date fire risk assessment and environmental risk assessments. Fire drills, alarm tests and other safety checks were taking place. The home was clean and well maintained. Inspectors judged that the previous legal requirements were now met.
People said they felt safe. Inspectors saw warm and positive interactions. Medicines were stored securely and records checked were complete. The overall rating was Good, but this inspection mainly focused on safety requirements.
Improved fire safety
The home had updated its fire risk assessment and was carrying out regular drills and alarm tests after the previous inspection.
“The registered provider had sought advice from the fire service since our last inspection, and was taking action to minimise risks, including four monthly fire drills and weekly fire alarm tests.” from the report
Safe medicines
Medicines were stored securely. Inspectors found that the administration records were complete and accurate.
“Medication administered was recorded on a Medication Administration Record (MAR) and our checks of MARs showed that these were accurately completed and contained no gaps or omissions.” from the report
People felt safe
The people living in the home said they felt safe, and inspectors saw relaxed and positive relationships.
“We observed warm and positive interactions between people and the registered providers, and people were relaxed and at ease in their home surroundings.” from the report
Clean and maintained home
Inspectors found the home clean and well maintained, with regular checks of areas such as water temperatures and fire alarms.
“The home was clean and well maintained.” from the report
One evacuation plan lacked detail
needs fixingThe evacuation arrangements for one person did not contain enough detail. Inspectors still judged that the legal requirements were met overall.
“The evacuation arrangements for one person still lacked detail, but overall we concluded that the registered provider was now meeting legal requirements.” from the report
Some review dates were missing
minorTwo risk assessment documents did not have their review dates recorded. The registered providers said they would be more careful about dating documents.
“We noted two examples where review dates were missed off documentation in error.” from the report
- 01What extra detail has now been added to the evacuation arrangements for the person identified in the report?
- 02How often are fire drills and fire alarm tests carried out now?
- 03How do you make sure all risk assessments have review dates and are updated when people's needs change?
- 04What is the plan if one of the registered providers is ill or cannot provide care?
- 05How are medicines checked when people administer their own medicines?
This was a focused inspection of the legal requirements linked to environmental risk, fire safety and emergency arrangements, with a current rating given for Safe rather than a full assessment of all five questions. This explanation was written from the published report of 17 January 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.
Every inspection of Yearsley Villa
3 rated inspections over 2 years: the service has held its Good rating throughout.
- June 2018Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2017Goodstayed GoodSafe: Good
- February 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 24 December 2010.
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.
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