Yearsley Villa

“We inspected the service due to the length of time since the last inspection. During this inspection we found the provider needed to make improvements.”

“There were positive aspects of care. Providers knew people well and we observed kind and compassionate interactions, with people treated with dignity and respect. People were supported to maintain relationships and access the community, and feedback reflected a relaxed, family-style environment. The environment was safe, clean, and well maintained, with appropriate safety checks in place. The provider collaborated with external professionals, including mental health teams, to support people when their needs changed.”

“However, significant improvements were required to ensure safe, effective, and well-led care.We found widespread concerns in relation to governance, care planning, and risk management. Care records were often incomplete, inconsistent, or lacked detail, and did not always reflect people’s current needs or how care should be delivered. There was limited evidence of person-centred planning, including people’s preferences, routines, and goals.”

“Risks were not always assessed or mitigated effectively. Risk assessments were either missing or lacked sufficient detail in key areas such as mental health, finances, and behaviours. Following incidents, there was limited evidence of review or learning, and appropriate safeguarding notifications had not always been submitted, which is a regulatory requirement.”

“We found concerns in relation to medicines management. Although people were described as self-medicating, there were no clear risk assessments, capacity assessments, or consistent systems to monitor this safely. There were also shortfalls in staff training and recruitment practices. Training was out of date in key areas and recruitment checks had not been consistently completed in line with the provider’s own policy.”

“We found consent and decision-making processes were not always in line with the Mental Capacity Act 2005. Capacity assessments and best interest decisions were either absent or not decision-specific, meaning we could not be assured that people’s rights were consistently protected.”

“There were no formal systems in place to audit quality, monitor risks or ensure compliance with regulations. Records were not regularly reviewed, and there was limited evidence of oversight or continuous improvement.”

“People had not been affected by the shortfalls identified. However, people were put at potential risk of poor care due to the concerns found during the inspection. We found 4 breaches of regulation. These are in relation to concerns surrounding the service’s governance, risk management, and lack of person-centred care. We found breaches of regulation in relation to medication management and consent to care. We have asked the provider for an action plan in response to the concerns found at this assessment.”

“The provider was receptive to feedback during the inspection and had started to make some improvements, including updating documentation. However, these changes were not yet embedded or sufficient to demonstrate sustained improvement.”