Yercombe (Gloucestershire) Trust

Updated 3 May 2023

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

The inspection was completed by 2 inspectors and an 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

Yercombe (Gloucestershire) Trust is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Yercombe (Gloucestershire) Trust is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the 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. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We reviewed the provider’s action plan. We used all this information to plan our inspection.

During the inspection

We spoke to 6 members of staff including the registered manager, 2 senior carers, 2 carers and a member of the board of trustees. We spoke to the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We spoke to 3 people using the service and 9 relatives of people to gain their feedback.

We reviewed a range of care records and risk assessments. We looked at 3 staff files in relation to staff recruitment. We reviewed a variety of records relating to the management of the service, staff development and the provider's policies and procedures.

We sought feedback from professionals and other agencies that work with the service.

Updated 3 May 2023

About the service

Yercombe (Gloucestershire) Trust is a small residential care home providing personal care for up to 11 people. The service provides support to older people, younger adults, and people with a physical disability. At the time of our inspection there were 10 people using the service.

Yercombe (Gloucestershire) Trust accommodates permanent residents and 2 people for respite care. People are supported in one adapted building over 2 floors set in a rural location. There is a day centre attached to the property used by people living at the service and members of the community. The provider is registered and operates as a charity.

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

Improvements had been made to the service following our last inspection.

People’s health associated risks were assessed and reviewed to reflect their changing needs. Risk management plans were made in collaboration with people, ensuring staff had detailed and individualised guidance on how to respond and manage people’s risks.

People were supported in the management and administration of their medicines. People received their medicines as prescribed, when they wanted them and how they liked them to be administered. Record keeping of people’s medicines was quality monitored by a medicines champion.

Environmental risks were managed to keep people and staff safe. Staff followed safe infection control practices and had access to personal protective equipment (PPE).

Staff were mainly recruited into the service safely and systems had been developed by the provider. Staff received a thorough induction, ongoing training, and supervision to support them in their roles.

People were supported by a core staff team who knew them well. Agency staff were introduced to people and people were provided choice in the gender of staff providing them care. We received positive feedback about the care being provided, relatives told us, “[People] often say how good the carers are” and “We could not wish for a better place.”

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.

Improvements had been made in the governance of the service. The registered manager and board of trustees had worked hard to develop and implement quality assurance processes and monitoring systems to ensure the safe running of the service. At the time of our inspection, some of these systems had not fully been embedded as more time was needed. Such as, quarterly analysis of trends from accidents and incidents.

The management team adopted an open culture of learning and growth. All staff were responsible for the ongoing improvement of the service, with the shared goal of the positive impact this would have on people. Feedback systems had been developed to gain the views of staff, people and relatives, which allowed them to contribute to the development of the service.

Staff worked in collaboration and communicated well with other agencies when supporting people.

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 requires improvement (published 17 January 2023) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

At our last inspection we recommended that the provider review their recruitment processes to ensure that all pre-employment checks were completed and recorded. At this inspection we found the provider had introduced a checklist for recruitment and auditing system to support them in safe recruitment decisions.

Why we inspected

We carried out an unannounced focussed inspection of this service on 9 November 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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.

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 Require improvement to Good. This is based on the findings at this inspection. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Yercombe (Gloucestershire) Trust on our website at www.cqc.org.uk.