Yewtree Avenue

Updated 25 March 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.

Inspection team

The inspection was carried out by 1 inspector and 1 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

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats.

This service also provides care and support to people living in 2 ‘supported living’ settings, so that they can live as independently as possible. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people’s personal care and support.

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. We sought feedback from the local authority and professionals who might 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 took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

We spoke with 6 people who used the service and 6 relatives about their experience of the care provided. We spoke with 6 members of staff including the registered manager, the care coordinator for the service and 4 care staff.

We reviewed a range of records. This included 7 people’s care and or medicine records, 2 of whom lived in supported living. We looked at 6 staff files in relation to recruitment. We also looked at a variety of records relating to the management of the service.

After our inspection visit to the service location, we continued to seek clarification from the provider to validate evidence found. This included speaking care staff. We analysed electronic call monitoring data sent to us by the provider and sought their response on our analysis.

Updated 25 March 2023

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 Care Quality Commission (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.

About the service

Yewtree Avenue (known as Blueboard Care Services) is a domiciliary care agency registered to provide personal care. At the time of the inspection 118 people were receiving care, 5 of whom lived in 2 supported living services the service managed.

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

Right Support

People had mixed views about staffing and our analysis showed improvements to call planning were required. The service told us they would address this. The service worked with other agencies to support people’s needs.

Right Care

Improvements had been made to medicines management since our last inspection and these were now managed safely. Similarly, improvements had been made to risk assessments and we found these were now being completed correctly and contained appropriate person-centred information.

There were systems in place to safeguard people from harm and abuse. Lessons were learned when things gone wrong. Infection control practice was robust as were recruitment measures.

Right culture

People had mixed views about the culture at the service, though staff were positive about the management. Similarly, there were mixed views about how the service engaged with people or relatives. Some told us they felt the service could improve in this regard.

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

Rating at last inspection (and what we found)

The last rating for this service was requires improvement (published 16 June 2021) and there were multiple 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 some improvements had been made but the service was still in breach of one regulation.

Why we inspected

We undertook this inspection to assess that the service is applying the principles of Right support, right care, right culture and to follow up on action we told the provider to take at the last inspection.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified a continued breach in relation to good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.