Yarborough House RCH

We carried out this assessment to follow up on previous enforcement action. The provider was previously in breach of the legal regulations in relation to safe care and treatment, staffing and good governance. Improvements were not found at this assessment, and the provider remained in breach of these regulations. We also found the provider was in breach of legal regulations in relation to nutrition and hydration and person-centred care.

Staffing levels were unsafe. Care staff were required to complete additional tasks alongside their caring duties, reducing the time available to support people. This meant people’s needs were not consistently met and people were at risk of having poor personal hygiene and risks to their health, safety and wellbeing remained.

Records showed several people had experienced unintentional weight loss and were at risk of malnutrition. Concerns relating to people's nutritional needs had not always been recognised or acted upon. In addition, referrals for people to relevant healthcare professionals had not been made in a timely way by staff. This placed people at risk of deteriorating health outcomes. Where people required texture modified diets and fluids, these were not always provided in line with professional advice and staff were not trained in textured diets. This meant people continued to be at risk of choking or aspiration.

Risks within the service were not always identified or addressed, such as fire safety and the provider could not be assured all equipment was safe for people and staff to use. Governance systems were ineffective as they had failed to identify shortfalls and drive improvement within the service. Repeated concerns identified through previous assessments and regulatory action remained evident, indicating lessons had not been learned, and required improvements had not been made. As a result, people continued to experience inconsistent care and poor outcomes.

Staff worked hard to support people and worked in accordance with the Mental Capacity Act whilst respecting people’s choices and decisions.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.