CQC report explained · a nursing home
What the CQC found at Yohden Hall Care Complex
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, September 2022
Rated Requires Improvement; inspectors found immediate safety fixes were made, but infection control, medicines checks and leadership were not consistently reliable.
This was an unannounced focused inspection on 10 and 16 August 2022. Inspectors looked only at Safe and Well-led, after concerns about medicines and staffing and routine infection control checks. They spoke with people, relatives and staff, and reviewed care, medicines and management records.
The home was not always safe. On the first day, infection control arrangements were poor, including missing hand gel and masks, unclear protective equipment stations and staff not always following COVID procedures. Checks had also not been completed after a treatment-room temperature became too high for safe medicine storage. The management support team acted straight away, and people received their medicines as prescribed.
The home was not consistently well-led. Leadership varied between units, and the changes being made had not been in place long enough to show they would work or last. The provider had identified problems through its quality checks and was addressing them, but some care and safeguarding records were incomplete.
The overall rating changed from Good at the previous inspection, published in February 2020, to Requires Improvement. The Safe and Well-led ratings were both Requires Improvement. The other three areas were not inspected at this visit and carried forward their previous ratings.
Kind treatment
Inspectors found that staff treated people with kindness and empathy. People were also protected from abuse and harm through safeguarding processes.
“Staff were kind to people and treated them with empathy.” from the report
Medicines given as prescribed
People received their medicines when they needed them. Staff administering medicines had suitable training and regular competency checks.
“People received their medicines as prescribed. Systems were in place to ensure people received their medicines when they needed them.” from the report
Quality monitoring
The provider's quality systems had identified failings, and the management support team responded quickly when extra support was needed.
“Quality assurance systems were effective. The provider had recognised failings in the home via their quality assurance systems and had started to address the issues identified.” from the report
Infection control
seriousOn the first inspection day, infection control arrangements were not effective. Some stations lacked washing facilities or hand gel, masks were not readily available and staff did not always follow COVID procedures.
“Effective infection and control prevention protocols were not in place on the first day of inspection.” from the report
Medicine storage checks
seriousStaff had not checked whether medicines remained safe after the treatment-room temperature rose above the appropriate level. The management support team addressed this immediately.
“Checks had not been conducted to confirm medicines remained safe when temperatures in a treatment room had raised above the appropriate levels.” from the report
Incomplete records
needs fixingSome safeguarding records were incomplete, and risks linked to particular health conditions did not always contain enough personalised detail. The provider had started reviewing records.
“Safeguarding concerns had been raised to the relevant authorities. However, records were not always complete.” from the report
- 01What checks are now carried out to make sure masks, hand gel and washing facilities are available at every infection control station?
- 02How do you check that staff follow COVID and other infection control procedures on every unit?
- 03How do you check medicine storage temperatures and what happens if a treatment room becomes too warm?
- 04What has changed in the leadership of each unit since the inspection?
- 05Have the reviews of care and safeguarding records been completed, and how do you check that risks are recorded with enough personalised detail?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection published in February 2020. This explanation was written from the published report of 2 September 2022 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, April 2021
Yohden Hall Care Complex was inspected but not rated; inspectors found good infection prevention and control arrangements.
Inspectors visited the home on 17 March 2021. This was an announced, targeted inspection during the COVID-19 pandemic. They looked at infection prevention and control measures.
Inspectors found that visitors had temperature checks and health declarations, and could be tested for COVID-19 on arrival. The home was clean, staff had enough protective equipment, and staff had guidance on using it safely.
The home was assured on visitor safety, social distancing, admissions, protective equipment, testing, hygiene, outbreak management and its infection control policy. The service was inspected but not rated, so this report does not give an overall quality rating.
Visitor checks
Visitors had health checks before entering, and relatives were supported to visit in line with national guidance.
“All visitors had a temperature check and completed a health declaration before entry.” from the report
Visiting arrangements
The home supported relatives to visit and tested visitors for COVID-19 on arrival.
“The home supported relatives to visit their loved ones in-line with national guidance.” from the report
Clean environment
Inspectors found the home clean, with regular cleaning of frequently touched surfaces.
“The home was clean, and staff were regularly cleaning frequently touched surfaces.” from the report
Protective equipment
Staff had guidance on using protective equipment and were following it.
“Staff had received guidance on correct PPE use and were following this.” from the report
Inspectors raised no specific concerns in this report.
- 01How are visitors currently checked before entering the home, and are visitors still tested on arrival?
- 02How are staff trained and checked on the safe use of protective equipment?
- 03How often are frequently touched surfaces cleaned, and how is this recorded?
- 04What is the current plan for preventing and managing an infection outbreak?
- 05What has changed since the targeted inspection on 17 March 2021?
This was an announced, targeted inspection of infection prevention and control measures; the service was inspected but not rated and the report does not assess the other care quality areas. This explanation was written from the published report of 15 April 2021 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 Yohden Hall Care Complex
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- September 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Inspected but not ratedSafe: Inspected but not rated
- February 2020Goodstayed GoodSafe: GoodWell-led: Good
- July 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 14 October 2011.
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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