Yarrow Housing Limited - 1-2 Elmfield Way

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 inspection we rated this key question good. At this inspection the rating has remained good. This meant people were safe and protected from avoidable harm.

People were kept safe from avoidable harm because staff knew them well and understood how to protect them from abuse. The service worked well with other agencies to do so. People were involved in managing risks to themselves and in taking decisions about how to keep safe. People’s freedom was restricted only where they were a risk to themselves or others, as a last resort and for the shortest time possible. Staff recognised signs when people experienced emotional distress and knew how to support them to minimise the need to restrict their freedom to keep them safe.

Accidents and incidents were monitored and analysed, so lessons could be learned, and recurrences could be avoided. The service followed robust recruitment procedures. The service had enough staff, including one-to-one support for people to take part in activities and visits how and when they wanted. When needed, the service also provided 2 members of staff to support people in the community. This helped ensure that individuals received personalised and safe support, tailored to their specific needs. The service ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines. Staff understood and implemented the principles of STOMP (stopping over-medication of people with a learning disability, autism or both) and ensured that people’s medicines were reviewed by prescribers in line with these principles. The service used effective infection, prevention and control measures to keep people safe, and staff supported people to follow them. The service had good arrangements for keeping the premises clean and hygienic.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People’s relatives said they felt their loved ones experienced good quality of care and lessons were learnt when things went wrong. One relative told us, they were always kept informed of any incidents and the staff always did their best to make sure changes were made to make things safer and prevent repeated incidents. One person who lived in the home told us they were listened to if they had any problems or raised any concerns.

Staff and the management team told us that people’s safety was a priority and it was everyone’s responsibility to make sure people’s safety was maintained. Staff and the management team told us the culture within the service was open and transparent and lessons were learnt from any accident or incident, to make things safer and better for people and avoid repeated incidents.

Staff told us reflections and learning were carried out during regular staff meetings and one to one supervision sessions. The management team told us that any issues around safety were reported and investigated and staff also knew who to escalate issues to.

The provider had effective systems and processes in place to ensure incidents and complaints were reported and investigated. We reviewed records relating to accidents and incidents and saw the manager recorded details of debriefs that had been held. In addition, they confirmed that incidents were discussed during team meetings for learning purposes and, collectively, the team established solutions to help prevent repeated occurrences. Minutes from team meetings were comprehensive and contained details of the discussions held with staff to help continually improve safety and the quality of the service.

People living in the home experienced safe systems, pathways and transitions. One person who lived in the home told us about a proposed transition from the home to a supported living service in the same vicinity. They were very knowledgeable about the proposals and timings and were being kept fully informed of progress by staff and the management team.

People’s relatives said they felt there was a collaborative and joined-up approach to help ensure their loved ones’ individual health, safety and wellbeing. One relative also told us about the planned change to the service. They said, “We’re kept involved and we’ve seen all the plans.”

Staff and the management team told us they were fully aware of their duty to work collaboratively and use a joined-up approach to safely support people living in the home. They gave examples of how they communicated and worked closely together within their own team, as well as with other healthcare professionals and people’s relatives.

Local authority commissioners confirmed that Yarrow Housing 1-2 Elmfield Way worked collaboratively with them and other healthcare professionals.

The provider had effective systems and processes in place to make sure that solid relationships with healthcare professionals were established to help maintain people’s safety. We saw evidence in people’s care records, which demonstrated effective communication and ‘joined up working’ throughout people’s care journeys. We also saw that the provider's policies, procedures, and processes were in line with current, relevant legislation.

Two people who lived in the service were not able to verbally tell us whether they felt safe, or their experience of safeguarding. However, during our observations, we saw their body language and behaviour towards staff was relaxed and positive. People appeared settled, comfortable and relaxed within their home environment, which indicated they felt safe. One person did tell us they felt safe living in the home and said staff supported them to stay safe.

People’s relatives told us they felt their loved ones were safe and looked after well by the staff. One person’s relative told us, “[Name] is very happy and looked after very well” and, “They [staff] always speak very kindly to [name].”

Staff and the management team we spoke with demonstrated a clear understanding of abuse and neglect and knew how to recognise signs that may indicate a person was at risk. Staff told us they were vigilant and explained how they understood people’s individual communication methods. They said they reported any concerns quickly and appropriately, which helped make sure people were protected from harm.

Staff and the management team confirmed that any restrictions on people’s freedom were only used when they were in the best interests of the person. They also had a clear understanding of the processes to follow in respect of Deprivation of Liberty Safeguards (DoLS), if people needed any restrictions for their safety. All the staff we spoke with confirmed they had completed training for safeguarding, as well as ‘reducing restrictive practice’.

Our observations during this assessment showed that staff were attentive to people, without being intrusive. Staff spoke kindly to people and treated them with dignity and respect. We saw people were familiar with the staff who supported them and their body language and behaviour towards the staff was relaxed and positive. All our observations provided assurance that people living in the home felt safe.

The provider had systems and processes in place to help ensure people were protected from abuse and neglect. We saw the safeguarding policies and procedures followed current and relevant legislation.

The provider’s quality performance manager confirmed that a Serious Incident Review process had been carried out to investigate the circumstances of a person’s recent accident. The local authority’s safeguarding team had also completed an investigation, from which there was no further action and the safeguarding case was closed.

At the time of this assessment, the systems we looked at showed that concerns about people’s safety were recorded and reported to the registered manager in the first instance. Following this assessment, as part of our factual accuracy process, the nominated individual confirmed the organisation’s internal processes. They explained that, if an incident was deemed reportable to the local authority safeguarding team and the Care Quality Commission (CQC), the registered manager would immediately notify these bodies. A copy of the notifications would be shared internally with the organisation’s Executive and Quality Team, who then provided support with any further action, including serious incident reviews, following the duty of candour processes and reporting to any other relevant bodies. Where appropriate, people and those important to them were involved in this process and informed about what action would be taken to keep people safe.

People’s relatives told us staff did their best to help keep people safe. One relative told us, “They take [name] for a walk around the garden or round the house. [Name] is not that great at walking. They (staff) got [name] a walking frame, but [name] won’t use it, so they have 2 carers with them in case they fall.”

One person who lived in the home told us they discussed various activities with staff, which helped them decide what support they needed to keep safe.

Staff and the management team confirmed that risk assessments were completed with people who used the service as much as possible. They told us they knew the people they supported very well and tried to help them understand and manage the various risks they encountered in their daily lives. Staff told us people’s care plans and risk assessments were regularly reviewed and updated as soon as any changes were needed.

We observed staff supporting people during our visit, which included undertaking their chosen activities. We saw and heard staff explaining to people, things that needed to be done to help them keep safe. The way staff communicated with people was by each person’s preferred method and at their own pace, which helped people process the information and understand what was being said to them and what they needed to do.

Prior to this assessment, we had discussed a person’s recent accident with the registered manager, the performance manager and the nominated individual. We highlighted some areas of concern regarding the content of the person’s support plan and risk assessments. The registered manager and the wider senior management team were responsive to our comments and took immediate measures to make improvements.

When we carried out this assessment, we found that risks to people were appropriately assessed, and care plans were in place to help staff prevent or minimise the identified risks, where possible. The risks included supporting people with their mobility, and personal care. This meant staff had up to date information about the action they should take to manage these risks and keep people safe. There were systems for staff to report concerns, incidents, and accidents. This enabled the provider to have oversight of and be able to manage risks. The management team completed regular audits and care plans updated if new risks were identified.

Only one person was able to tell us about the environment they lived in. This person said they felt their home was safe, although there were some things that needed fixing. They told us that 1 of the bathrooms was ‘out of action’ due to damp, so it was being dried out before being refurbished. This person said staff were keeping them fully updated regarding progress.

People’s relatives told us they felt the environment was clean and safe. They said the service also obtained and safely maintained appropriate equipment for people to use, as needed. One relative said, “[Name] has a nice room. It’s got all [name]’s photos on the wall. It’s always nice and clean. The toilets are always clean.”

Staff and the registered manager told us they were aware of the areas in the home that required attention and confirmed that action was already in the process of being completed. Following this assessment, the regional manager provided appropriate evidence to confirm the repair works had all been completed.

At the time of this assessment, we observed some areas within the home that were ‘tired’ and in need of attention. However, we were assured that these issues had been reported and the repairs were scheduled to take place very soon. In the meantime, we were also assured by our observations that the environment and equipment was being kept as safe as possible for the people living and working in it.

We saw the provider had effective systems and processes in place for identifying and reporting areas where repairs and maintenance needed to be carried out. There were also processes in place to ensure the issues reported were followed up and the necessary action taken in a timely way.

Only one person was able to tell us about the staff in the home. They said the staff were really good and gave them the support they needed, when they needed it. They said staff helped them to be able to do the activities they wanted to and gave an example of doing the weekly house shopping with support from staff, which we observed during our visit.

A person’s relative told us, “There’s plenty of staff. They’ve also got bank staff if people go off sick. We can’t fault the staff. They’re definitely all well trained and they have meetings every Monday. They’re all good.”

The staff and management team told us there was always a very good staff ratio to be able to fully support the people living in the home, in the way they wanted and needed. Staff told us they felt well supported by the management team and said they were always available when needed.

During our visit we observed there were enough staff to support people appropriately. The numbers of staff were consistent with the rotas and the support requirements for people, as stated in their support plans. We saw staff treated people kindly and were patient and caring towards them. We also saw there was an allocated additional staff member available to help provide one-to-one support for people when needed.

The provider had safe and effective systems in place to help ensure staff recruitment was thorough and robust. Records we looked at demonstrated that the recruitment processes were followed accordingly. Staff disciplinary and capability processes were fair and regularly reviewed. This helped ensure staff were not disadvantaged because of any protected equality characteristics they may have. Staff completed comprehensive training that was appropriate and relevant to their role. They were also supported to deliver safe care by receiving regular supervisions, appraisals and development support and by being encouraged to be actively involved in improving the service.

People’s relatives told us they felt the home was clean and hygienic and staff followed appropriate infection control procedures.

Staff and the management team told us they followed infection control procedures and fully understood the importance of keeping the home and equipment clean and hygienic.

During our visit we observed that staff followed appropriate hygiene practices, which were in line with current guidance. Staff also supported people living in the home to avoid infections or cross contamination, by encouraging them to maintain their personal hygiene. We saw the home and equipment were kept clean. Areas that required repair or refurbishment, which were difficult to keep clean, had been documented and reported.

The provider had effective systems and processes in place to minimise the risk of infection and ensure there was a clean and hygienic environment for people to live and work in. We saw there were cleaning schedules in place, which staff followed and this area was regularly audited. We also saw that staff had completed training for infection prevention and control, as well as food safety and health and safety.

People experienced safe support from staff with regard to their medicines. People were given their medicines by staff as prescribed, this was recorded on their medicines administration record (MAR) by the staff. Person centred guidance was in place to support people to have their ‘when required' medicines (including for medicines that might control behaviour) when they need them. People’s medicines were reviewed using STOMP (stopping over-medication of people with a learning disability, autism or both) principles. People were safe from abuse, medicines were not used to control people’s behaviour. People were supported by staff who understood their individual medicines needs, for example, people who experienced seizures had risk assessments and care plans in place.

Staff told us they had completed medicines training and their competency was assessed, to make sure they could support people with their medicines safely. Evidence we saw during our visit corroborated what staff told us. For example, medicines were signed for correctly and given as prescribed.

The provider had effective systems and processes in place to ensure the safe management and administration of people’s medicines. Medicines were given as prescribed and recorded on the medicines administration record (MAR). Medicines risk assessments were carried out and reviewed regularly. The staff received training and were competency assessed to handle medicines safely. Regular medicines audits were carried out to identify gaps and make improvements. There was a process in place to report and investigate incidents.