Yourlife (Hertford) received an overall Good rating across all five key questions at its first CQC inspection in April 2021, with staff demonstrating strong safeguarding awareness, safe medicines management, and a caring, person-centred approach. Minor improvement areas were identified including inconsistent care plan quality, gaps in risk assessment detail, absence of the registered manager since February 2021, and the need to embed higher-level dementia and end-of-life training.
Concerns (7)
moderateRecord keeping: “Risk assessments had not always been updated when a person's needs changed and also lacked detail in some examples seen.”
moderateCare planning: “The quality of information recorded in the care plans was inconsistent. Some contained detailed person-centred information, others were not completed to the same standard.”
minorStaff training: “Further higher-level training was required in areas such as dementia.”
minorIncident learning: “Learning and sharing from lessons needed embedding with staff.”
minorStaffing levels: “Staff had not always stayed for the agreed length of the call. This had been identified by the management team, who were addressing this at the time of inspection.”
minorEnd-of-life care: “Advanced care plan templates were within people's care plans but were yet to be discussed or completed with people.”
minorLeadership: “The registered manager had been absent from the service since February 2021...recent changes with the registered manager had left staff and relatives feeling anxious and uncertain.”
Strengths
· Staff demonstrated clear understanding of safeguarding responsibilities and reporting processes.
· Robust recruitment procedures including DBS checks and satisfactory references for all staff.
· Medicines administered safely with completed MAR records and regular management checks.
· Staff and management worked effectively with external professionals including GPs and occupational therapists.
· Relatives praised the kind, caring and professional nature of the staff team.
Quality-Statement breakdown (21)
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving care; Working in partnership with othersGood