CQC report explained · a residential care home
What the CQC found at York House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Inadequate
- Risk assessments were missing, lacked detail or conflicted with care plans. Incidents were not always reported or investigated, and the night shift did not always include a staff member trained to administer medicines.
- Effective?
- Requires improvement
- Mental capacity assessments and best-interest meetings were not completed for some decisions or restrictions. Staff had not received additional training about some people's mental health or physical conditions.
- Caring?
- Requires improvement
- Staff were often focused on tasks rather than social interaction, involvement and wellbeing. People and relatives were happy with the care, and inspectors found that privacy, dignity and presentation were maintained.
- Responsive?
- Requires improvement
- People were not always involved in care planning and had no recorded goals. Activities were very limited and were not consistently based on people's interests.
- Well-led?
- Requires improvement
- Quality audits did not identify important problems with care plans, risk assessments and incidents. The manager was responsive to inspectors' concerns and the home worked well with other professionals.
What inspectors found, January 2024
York House was rated Requires Improvement overall, with Safe rated Inadequate; inspectors found risks, staffing and activity support needed urgent improvement.
This was an unannounced inspection. One inspector and an Expert by Experience visited on 16 November 2023. The inspection activity ended on 29 November 2023. Inspectors spoke with one person, two relatives and six staff. They reviewed three care files, two staff files and service records.
The home was not always safe. Risk assessments were missing or unclear, some incidents were not reported or investigated, and there was no trained medicines staff member on the night shift. Medicines competency checks had also not been completed. Inspectors found no evidence that people had been harmed by these concerns.
Inspectors also found weak support for people's independence, choices and meaningful activities. Mental capacity checks and best-interest decisions were not properly recorded. Quality checks did not identify important problems. People and relatives were nevertheless positive about the staff and manager, and people received their medicines as prescribed.
The overall rating fell from Good at the previous inspection in 2016 to Requires Improvement. Safe was rated Inadequate, while Effective, Caring, Responsive and Well-led were all rated Requires Improvement.
Positive views of care
People and relatives told inspectors they were happy with the care and felt at home. Professionals also gave positive feedback about the service.
“People and their families were happy with the care provided.” from the report
Medicines given as prescribed
Relatives said people received their medicines daily and were supported by staff.
“From what I understand medication is given daily and support provided by staff.” from the report
Communication plans
Care plans recorded people's communication needs and gave staff guidance about how to communicate clearly, including when someone was distressed.
“People's care plans included details of their communication needs.” from the report
Choice of food
People were involved in menu planning and could choose what they ate and drank. Dietary requirements were accommodated.
“We all get together; we all choose what we want.” from the report
Access to outdoor space
People had access to a large garden and different indoor areas, including a quiet room and spaces with or without television.
“People had access to a large garden with plenty of seating.” from the report
Incomplete risk information
seriousSome risk assessments were missing or did not match the care plans. Staff were not always aware of important risks, including choking and diabetes.
“Some risk assessments were missing or lacked detail and some conflicted with information in the care plan.” from the report
Incidents not properly managed
seriousAn incident had not been reported, and two reported incidents had not been investigated. There was no clear evidence that lessons had been shared to prevent a repeat.
“Two incidents had been reported; these had not been investigated and there was no evidence of what had been done or lessons learned shared with staff.” from the report
Night staffing and medicines checks
seriousThere was only one staff member on the night shift, and that person was not trained to administer medicines. The manager had not completed medicines competency assessments.
“There was 1 member of staff on shift at night, but they were not trained in medicine administration.” from the report
Limited activities and goals
seriousPeople had no recorded goals and very little meaningful activity. Activities were not consistently personalised or linked to people's interests.
“During our visit, no activities were planned, and people were sitting in communal areas with no stimulation.” from the report
Restrictions not properly assessed
needs fixingThe home had not completed capacity assessments or recorded best-interest decisions for some restrictions. Less restrictive options had not always been considered.
“The registered manager had not ensured mental capacity assessments were completed or held best interest meetings for decisions.” from the report
Weak quality monitoring
seriousAudits did not identify problems in care plans, risk assessments and incident management. There was no tracker to identify patterns or learning from incidents.
“The service's quality assurance systems and processes were not effective to monitor and improve the quality and safety of the service.” from the report
- 01What has been done to make sure every person's risk assessment matches their care plan, particularly for choking, diabetes and behaviours?
- 02Who will administer medicines overnight, and can you show us the completed training and competency checks?
- 03How are incidents now reported, investigated and reviewed for repeated patterns or lessons?
- 04What personalised activities and daily living goals will be offered to my relative?
- 05How will you complete and review mental capacity assessments and best-interest decisions for any restrictions?
This was an unannounced inspection covering all five CQC questions, including the premises and care provided; inspectors reviewed three care files, two staff files and service records. This explanation was written from the published report of 17 January 2024 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 7 years: the service has slipped, from Good to Requires improvement.
- January 2024Requires improvementcurrent ratingdown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 2 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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