Yellow Rose Healthcare Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question as requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. During this assessment we found the provider was in breach of legal regulation in relation to safeguarding people. We identified the provider was in a continued breach of legal regulation in relation to safe care and treatment.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately. The registered manager was responsible for ensuring safeguarding referrals were made to the local authority and to the Care Quality Commission (CQC) as required. The registered manager confirmed they raised safeguarding concerns with the local authority. We found however 1 safeguarding notification had not been made as required to CQC. We also found 1 safeguarding concern raised by the ambulance service had no confirmation of how the person was now being supported with their medicines. The provider had no quality assurance system in place that logged incidents, accidents and any safeguarding concerns. This meant themes and trends could not be identified including any actions needing to be taken to keep people safe. These included notifications being made to CQC when required. We were not assured staff were receiving safeguarding training as part of their induction. The registered manager sent confirmation all staff had attended training in June 2024. There was however no confirmation safeguarding training had been provided to staff prior to this date. We were unable to speak to staff about this as staff contact details requested were not provided as part of this inspection. People’s care plans contained important information such as any medical diagnosis that could affect them making their own decisions. Care plans were not clear about whether people had mental capacity to make specific decisions. We also found there had not been a mental capacity assessment undertaken for 1 person who lacked capacity. People and relatives felt supported by staff who they described as caring.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People and relatives felt care was provided by staff who were polite and who knew them well. A relative told us, “They are aware of what support is needed.” People’s care plans contained important information such as how staff were to support them with their mobility. Risk assessments were undertaken such as for mobility and nutrition, although environmental risk assessments were not being completed. We found 1 person needed a risk assessment around the management of their medicines following an incident, but this had not been completed. The provider had no quality assurance systems in place to monitor the quality of people’s care plans so improvements could be made. Referrals were made to professionals such as social workers and occupational therapists when required. People’s care plan’s contained personal information such as their emergency contact and GP details. We requested staff contact details as part of this inspection, but they were not provided. This meant we were unable to speak to staff to gain clarity on how they supported people in managing risks.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. The service did not work to always ensure they provided safe care that met people’s individual needs. People and relatives told us care visits from staff were not always being provided when they were expected. A person told us, “They don’t always arrive on time.” A relative told us, “They can be an hour late.” Another relative told us, “There have been missed calls as well as calls being an hour and a half late.” We were not assured staff were receiving supervision, training and an induction to ensure they had the skills and qualifications to undertake their role and responsibilities as required. For example, we found there was no confirmation of what induction new staff had undertaken or what training they had been provided with at the start of their employment. Staff had not received practical training in areas such as Learning Disabilities and Autism. This meant staff might not have the knowledge and understanding to support people with these specific needs. There was no information of when staff had completed their care certificate. There was some supervision records and spot checks available but the number was limited. The registered manager confirmed staff meetings were held, but there were no minutes or documentation available to confirm when they had occurred nor what had been discussed. Staff contact details were requested but not provided to us during this inspection. We were therefore unable to speak to staff to gain clarity on what training, supervision and support they received. Recruitment processes were in place and people were supported by staff who had suitable checks completed prior to working in the service. This included reference checks, identification checks and a disclosure and barring service check on their suitability to work with vulnerable adults.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.