CQC report explained · a residential care home
What the CQC found at York House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2019
York House was rated Requires Improvement; inspectors found kind, person-centred care, but medicines were not always managed safely.
Inspectors visited on 8 and 14 October 2019. The first day was unannounced. They spoke with people, a relative, staff and healthcare professionals. They also observed care and checked care, medicines, staff and management records.
The home was rated Good for Effective, Caring and Responsive. People were generally positive about the care. Staff were described as kind and caring, and inspectors found people were treated with dignity, offered choices and supported to stay independent.
The home was rated Requires Improvement for Safe and Well-led. Inspectors found errors and gaps in medicines management, including wrong doses, missing records and missing guidance for one medicine. The home remains Requires Improvement for the second inspection in a row. CQC required an action plan and will monitor progress before re-inspecting.
Kind and respectful staff
Inspectors saw warm relationships between staff and people. Staff knew people's preferences and treated them with dignity.
“It was clear people and staff had formed good relationships.” from the report
Personalised care
Care records gave staff information about people's needs, preferences and history. People were offered choices and encouraged to remain independent.
“Care records were person centred and contained sufficient information for care staff to be able to meet people's assessed need.” from the report
Improved staffing and risk planning
The home had enough staff based on its assessment of people's needs, and earlier breaches about staffing and risk management had been resolved.
“At this inspection we found enough improvement had been made and the provider was no longer in breach of regulation 18.” from the report
Good activities and community links
The home offered trips, games, creative activities and visits from local children. People also attended a local dementia café.
“Activities included day trips, shopping trips, films, games, reminiscence quizzes and rummage boxes and boards.” from the report
Medicines were not always safe
seriousInspectors found wrong doses, a medicine that was given but not recorded, and missing guidance for an as-needed medicine. This was a breach because the systems did not reliably show that medicines were managed safely.
“People did not always receive their medicine as prescribed.” from the report
Checks did not identify medicine problems
seriousAlthough audits were in place, they had not picked up the medicines concerns. The provider introduced extra checks after the inspection.
“However, we found concerns regarding medicines management as identified earlier in our report had not been identified through the existing checking processes and quality audit systems.” from the report
Some information needed improvement
needs fixingThe manager was not aware of the Accessible Information Standard. Some end of life records also contained limited personal information about people's wishes.
“However, we found some care records recorded limited person-centred information relating to end of life wishes.” from the report
Minor cleanliness issues
minorInspectors found one piece of moving and handling equipment was not clean and noticed a bad smell in an upstairs corridor. These were raised with the manager.
“We identified a piece of moving and handling equipment was not clean and there was a malodour on an upstairs corridor.” from the report
- 01What changes have you made to prevent wrong medicine doses, missed records and missing guidance for as-needed medicines?
- 02How are medicine records and stock levels now checked, and who reviews the results?
- 03What progress has been made on recording people's personal end of life wishes?
- 04How do you now provide information in accessible formats for people with communication needs?
- 05How do you check that staffing levels remain enough when staff are off sick or the home is busy?
This was a comprehensive inspection covering all five CQC questions, including the premises and care provided; the previous Requires Improvement rating was reviewed. This explanation was written from the published report of 20 November 2019 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, October 2018
York House was rated Requires Improvement; inspectors found kind care but serious problems with staffing, records, medicines and management.
This was an unannounced inspection. Inspectors observed care and mealtimes, reviewed seven care files and four medicines records, and spoke with people living at the home, a relative, staff and a visiting professional. It was the first inspection since the home was registered under a new provider.
The home was not always safe. There were not enough staff available at some times, risk plans were incomplete and medicines records did not always match the actual medicine counts. Records about food, fluids, consent, mental capacity and people's care were also incomplete or inconsistent.
Inspectors saw that staff were kind, respectful and understood safeguarding procedures. However, staff often had little time to talk with people, care was not always personalised, and there was very little meaningful activity. All five areas were rated Requires Improvement, meaning the home was not consistently meeting the required standards and needed to make improvements.
Kind and respectful staff
Permanent staff knew people well and were observed treating them with kindness, care and respect.
“Our observations during the inspection concluded that permanent staff knew people very well and were very respectful and kind with people.” from the report
Safeguarding knowledge
Staff understood how to recognise and report possible abuse.
“All the staff we spoke with demonstrated they understood how to ensure people were safeguarded against abuse and they knew the procedure to follow to report any incidents.” from the report
Complaints were handled
The home had a complaints process, investigated formal complaints and held meetings with relatives about concerns and planned improvements.
“One relative we spoke with told us they had used this opportunity to air their concerns and they were happy with the response.” from the report
Provider had identified problems
A detailed provider audit found important weaknesses and an improvement plan had been started.
“The registered provider had completed a very robust audit which had picked up the issues and had an improvement plan in place” from the report
Clean environment
Inspectors found the home clean overall, with protective equipment readily available. They also saw that the home had recently had a deep clean.
“We observed the home was clean and staff had access to plentiful supplies of protective aprons and gloves.” from the report
Not enough staff at some times
seriousStaff were not always available in communal areas, and some people had to wait for care or could not get up or go to bed when they wanted.
“However, from our observations we concluded there were not enough staff to provide a safe service.” from the report
Risk and equipment records
seriousSome risks did not have linked plans explaining how staff should reduce them. Equipment needs, sling details and equipment checks were not always recorded clearly.
“Risk assessments around the risk of falls, choking, moving and handling and mobility had also recently been completed although the associated risk reduction plans were not all in place.” from the report
Medicine recording
seriousInspectors observed medicines being given safely, but medicine counts did not consistently match the records. Records for applying creams were also missing for some people.
“We checked the count of four medicines and only one was correct.” from the report
Incomplete care records
seriousSome care plans were not personalised, were inconsistent or were incomplete. This meant staff, particularly agency staff, did not always have an up-to-date guide to people's needs and preferences.
“The quality of the record keeping varied and some care records we looked at were not personalised, were inconsistent and in many instances incomplete.” from the report
Food and fluid monitoring
needs fixingRecords did not reliably show how much people had eaten or drunk. Information about weight loss and people's nutritional needs did not always agree across records.
“However, the records were not consistently completed, and it was unclear how much of their meal people had eaten.” from the report
Little meaningful activity
needs fixingThere was very little occupation during the inspection. The activities coordinator was not able to focus on activities because of staffing pressures.
“But this was a very small part of people's days and for the most part people were sitting without any means of occupation.” from the report
- 01How many permanent and agency staff will be working on each shift, and how will you make sure people are not left waiting for care?
- 02Have all residents' risk reduction plans, moving and handling equipment details and mattress settings now been completed and checked?
- 03How are medicine counts and cream records checked each day, and what happens when the records do not match?
- 04Have care plans been rewritten to include each person's preferences, life history, consent, mental capacity and end-of-life wishes?
- 05What regular activities are now available, including for people cared for in bed or who prefer to stay in their rooms?
This was an unannounced comprehensive inspection covering all five CQC questions; it was the first inspection since the home was registered under a new provider, although the report gives two different descriptions of the first inspection date. This explanation was written from the published report of 9 October 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.
Every inspection of York House
2 rated inspections over a year: the service has held its Requires improvement rating throughout.
- November 2019Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2018
Registered with the Care Quality Commission on 12 February 2018.
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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