Yohden Hall Care Complex

Updated 2 September 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by two inspectors and one Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Yohden Hall Care Complex is a ‘care home’. People in care homes receive accommodation and nursing as a single package under one contractual agreement dependent on their registration with us. Yohden Hall Care Complex is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection the registered manager had recently stepped down from their post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with five people who used the service and eight relatives about their experience of the care provided. We spoke with 12 members of staff including a quality excellence partner, two service support practitioners, a nurse, a life-style co-ordinator, two administers, and five care workers.

We reviewed a range of records. This included five people’s care records and multiple medication records. A variety of records relating to the management of the service.

Updated 2 September 2022

About the service

Yohden Hall Care Complex is a nursing care home providing personal and nursing care to 77 people. The service is split into four units and one unit accommodates up to ten people with a learning disability. At the time of the inspection there were 53 people using the service.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

People’s experience of using this service and what we found

Right Support:

Yohden Hall Care Complex is a large home which is separated into four different units. The unit that supported people with a learning disability had ten available rooms. This is larger than current best practice guidance. Effective infection and control prevention protocols were not in place on the first day of inspection. Staff did not always respond quickly to assess the safety of medicines. The management support team addressed these matters immediately. People received their medication as prescribed. Staff supported people to access external healthcare professionals when needed. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Right Care:

The provider had systems in place to ensure people were protected from the risk of abuse and harm. Staff were kind to people and treated them with empathy. Environmental and individual risks were identified and managed. The provider was completing a review of care records to make improvements.

Right Culture:

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. The provider responded quickly when extra support was needed in the home to ensure people received good quality and safe care. Whilst the management support team had strong presence in the home, individual units lacked leadership, for example IPC management was poor on our first day. The management support team gave staff clear guidance on where improvements were needed and how these were to be achieved. The management team were in the process of making improvements to the service. These were not fully embedded therefore evidence was not available to confirm the changes were effective or would be sustained.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was good (published 4 February 2020)

Why we inspected

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We received concerns in relation to the management of medicines and staffing. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.