CQC report explained · a residential care home
What the CQC found at Yercombe (Gloucestershire) Trust
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People's risks were assessed and reviewed, medicines were administered and recorded safely, and infection control arrangements were effective. Inspectors also found enough staff and improvements in recruitment processes.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used to calculate the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used to calculate the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used to calculate the overall rating.
- Well-led?
- Requires improvement
- Management and governance systems had improved, and the provider was no longer in breach of regulation 17. However, some systems had not yet been fully tested or embedded, including quarterly accident trend reviews and recruitment auditing.
What inspectors found, May 2023
Yercombe (Gloucestershire) Trust is rated Good overall; inspectors found safer care and kind staff, but leadership systems still needed more testing.
This was an unannounced focused inspection on 21 and 22 March 2023. Inspectors spoke with people, relatives, staff, managers, trustees and other professionals. They reviewed care records, risk assessments, recruitment files, medicines records and management systems.
The home was rated Good for Safe. Inspectors found that risks were assessed and reviewed, medicines were managed safely, infection control was effective and there were enough staff with suitable skills. People said they felt safe and relatives spoke positively about the care.
The home was rated Requires Improvement for Well-led. The provider had made substantial progress since the previous inspection and was no longer in breach of regulations. However, some new checks, including reviews of accident trends and recruitment audits, had not yet been fully tested or embedded.
The overall rating was Good. The other key questions were not inspected during this visit, so their previous ratings were used when calculating the overall rating.
Individual risk planning
The home assessed and reviewed health-related risks, involving people in their risk plans. Staff had detailed guidance about how to respond to individual risks.
“People were involved in the development of their risk assessments which guided staff in how to minimise and respond to risks in an individual way.” from the report
Medicines
Inspectors found clear medicines records, audits and stock checks. A medicines champion helped identify and address errors.
“People received their medicines as prescribed when they wanted them. Clear records were made when staff supported people in administering medicines” from the report
Kind and familiar staff
People were supported by a core staff team who knew them well. Relatives said staff were friendly, caring and had time to talk.
“The carers have time to stop for a chat with [people], it never looks like they are just doing a job.” from the report
Listening to feedback
The home had introduced meetings, surveys and review meetings for people and relatives. Inspectors found that feedback was acted on.
“People and relatives views were actively gathered and acted upon.” from the report
New checks not yet proven
needs fixingSome governance systems were still new and had not been fully tested. Inspectors could not yet see whether accident trend reviews and recruitment audits were effective in reducing risks.
“However, some governance systems had not had the opportunity to be fully tested and embedded.” from the report
- 01How have the quarterly reviews of accidents and incidents worked since the inspection?
- 02What did the recruitment audits find after enough new staff had been recruited to test the system?
- 03How are medicines audits, stock checks and medicine errors reviewed now?
- 04How will you show that risk assessments continue to change when people's needs change?
- 05How are people and relatives' feedback and concerns recorded and acted on?
This was an unannounced focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous inspection. This explanation was written from the published report of 3 May 2023 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 2023
Yercombe (Gloucestershire) Trust was rated Requires Improvement; inspectors found safety and management failures and issued warning notices.
This was an unannounced focused inspection. Inspectors visited on 9 and 10 November 2022, spoke with people, relatives and staff, and checked care records, medicines, recruitment, training and quality checks.
People said they felt safe and praised the permanent staff and homely atmosphere. However, risks were not always assessed properly, medicines records and administration were not always safe, emergency procedures were not understood by all staff, and infection control practices were inconsistent.
The home was rated Requires Improvement overall. Safe was rated Requires Improvement and well-led was rated Inadequate. The previous overall rating was Good, published in January 2020. The report says the provider must improve and that CQC will continue to monitor progress.
People felt safe
People and relatives told inspectors they felt safe and well looked after.
“I feel safe and secure” from the report
Kind permanent staff
People and relatives spoke positively about the permanent staff, who were described as approachable and kind.
“[permanent] staff are amazing, very approachable, do what they can for you.” from the report
Homely environment
People liked the home and inspectors observed cleaning taking place. People said their rooms were kept clean.
“[the home is] absolutely clean and tidy everywhere.” from the report
Mental capacity practice
Inspectors found that the home was working within the principles of the Mental Capacity Act, with appropriate legal authorisations where needed.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.” from the report
Risk assessments and falls
seriousSome risks, including falls, moving and handling, choking, epilepsy, skin integrity and catheter care, were not fully assessed or covered in care plans. Staff did not always know how to respond to emergencies or monitor people after falls.
“People's risks had not always been assessed and care plans were not always completed where required.” from the report
Medicines safety
seriousMedicine records were not always completed correctly. Inspectors found problems with transcribing medicines, pain patch use, topical medicines and storage temperature records.
“Good practice was not always followed when staff transcribed people's medicines onto their Medicine Administration Records.” from the report
Infection control
seriousSome staff did not follow expected infection control practices. The home also lacked a Covid-19 outbreak procedure and had unclear arrangements for cleaning equipment.
“We were not assured that all staff, at all times, were adopting good infection, prevention and control practices.” from the report
Weak management checks
seriousQuality systems did not identify or resolve important concerns about risks, medicines, infection control, incidents and fire safety. Incidents were not always recorded, investigated or analysed.
“The provider's quality and risk monitoring systems did not identify the concerns we found at this inspection.” from the report
Limited feedback
needs fixingRelatives and staff had few formal ways to give feedback about the service. The report says the home did not have a staff survey or suggestions box.
“There was a lack of systems to seek and act on feedback to improve the service.” from the report
Agency staff and recruitment records
needs fixingAgency staff were being used when the home was short staffed, and some people were not introduced to them or offered a choice of carer. Recruitment records did not always show that previous employment concerns had been fully checked.
“Sometimes I have not been introduced to agency staff.” from the report
- 01What has been changed to make sure every resident's risks, including falls, choking, epilepsy and moving and handling, are assessed and clearly recorded?
- 02How are medicines now checked, including pain patches, topical medicines and medicine administration records?
- 03What is the current procedure for managing a Covid-19 or other infection outbreak, and who is responsible for cleaning equipment such as hoists?
- 04How are accidents, near misses and falls recorded, investigated and reviewed for patterns?
- 05What evidence can you show that the warning notices have been acted on and that the quality monitoring system is now working?
This was a focused inspection of Safe and well-led only; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 17 January 2023 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 Yercombe (Gloucestershire) Trust
5 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- May 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Yercombe (Gloucestershire) Trust →
- January 2023Requires improvementdown from GoodSafe: Requires improvementWell-led: Inadequate
Read what inspectors found at Yercombe (Gloucestershire) Trust →
- January 2020Goodstayed GoodSafe: GoodWell-led: Good
- August 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- October 2010
Registered with the Care Quality Commission on 1 October 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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38 live-in carers within about an hour of Gloucestershire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,030 to £1,360 a week. 31 can care for a couple. 12 years' experience on average.
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.