Newgate Lane

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained the same. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not consistently promote a proactive culture of safety. Staff did not always respond to concerns in a timely manner, and systems for investigating and learning from safety incidents were inconsistently applied.

Although processes existed to review events and identify trends, these were not consistently used to drive timely improvements. Incidents were not always thoroughly investigated to determine causes, and actions put in place to prevent recurrence were sometimes delayed. For example,investigation completion of two medication-related incidents report on the 14th and 29th March exceeded 30 days in line with the providers policy without rationale for exceeding this timeframe. Earlier investigation could have reduced the risk of recurrence and ensured corrective actions were implemented more promptly.

People told us if they weren’t happy, they would talk to staff. Staff told us where they would record incidents and that de-briefs took place following these being reviewed by the manager. ‘Make your views known’ forms were shared with families.

A professional told us “The team and the home manager appeared to be proactive and acting upon the received feedback in a timely manner.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were appropriate referral processes in place which included input from families and professionals. People also had a “find my housemate” form which highlighted a person’s likes and dislikes when identifying people they would like to live with.

Hospital passports were in place as part of the services commitment to safe systems and effective transitions.

A family member told us, “I think it was first rate, no issues at all, they were brilliant, before [relative] moved in, I met with the manager a couple of times and went to see the home.”

The provider had safeguarding systems in place. Safeguarding concerns were shared appropriately in a timely manner. However, there was not a clear understanding of the Deprivation of Liberty Safeguards (DoLS) which meant people’s rights and freedoms were not always upheld.

People can only be deprived of their liberty to receive care and treatment when they are assessed as lacking capacity, it is in their best interests and legally authorised. We found an application had been made to deprive a person, who had been assessed as having capacity to consent to their care and treatment, of their liberty. Another person’s records stated they were unable to leave the home without staff support, could not be left unsupervised and an application to deprive them of their liberty had been made. However, there was no mental capacity assessment of evidence of how this decision had been reached. This meant people were at risk of not having their rights upheld.

People’s relatives told us they felt their relatives were safe. Staff had completed safeguarding training in relation to both adults and children and knew how to escalate any concerns.

The registered manager reported safeguarding concerns in accordance with their legal responsibilities in relation to the submission of statutory notifications to the Care Quality Commission (CQC).

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider did not manage choking risks safely. Records did not clearly demonstrate people were given food in line with the modified texture in line with speech and language therapy assessments or risk management plans in place. Staff were not able to consistently and correctly describe the guidelines on how to prepare foods to the correct texture for people. Not all staff preparing foods had undertaken dysphagia training.

Other risks to people’s health, safety and well-being were appropriately assessed with clear management plans in place. Overall, risk assessments were detailed. Individual risks were identified in peoples plans and any changes were shared with staff.

People had personal emergency evacuation plans (PEEP) in place which detail how a person needs to be supported in the event of a fire. A professional told us “The home appeared proactive and willing to look into equipment and reviewing the processes of safety around evacuating for the gentleman I have worked with.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Systems were in place to monitor, identify and report any safety concerns.

Relevant health and safety certificates were in place. The provider ensured all required safety and maintenance checks were undertaken on any equipment used including hoists and wheelchairs.

Although the environment was safe, communal areas of the service were worn or not well maintained. Where identified issues were the responsibility of the landlord there was evidence of the provider sharing these concerns with them including decoration.

Relatives told us the environment was safe for their loved ones.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

Staff and relatives told us there were enough staff on shift. Staff told us they had a thorough induction when joining the service and received ongoing supervision and support. The provider ensured staff received training relevant to their role.

The registered manager oversaw staff performance, undertook supervisions and provided support where needed. The provider undertook safe recruitment processes and pre-employment checks. This included obtaining right to work information, evidence of conduct in previous employment and disclosure and barring service (DBS) checks.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Systems were in place to monitor, identify and report any concerns. Staff completed infection, prevention and control training. Handwashing facilities, signage and personal protective equipment (PPE) was available throughout the building.

We observed staff wearing PPE appropriately when supporting people and the building was visibly clean. Infection control policies were available to staff. Relatives told us the service was clean.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. The service identified and managed risks associated with medicines. There was detailed information available to staff to enable them to safely administer medicines. Information was person centred, enabling staff to meet people’s needs and preferences.

People’s health was reviewed annually. Medicines doses were reduced or in some cases discontinued where they were no longer of benefit to avoid overmedication and there was evidence of discussions about people’s medicines in staff meetings.

Medicines management systems had improved since the last inspection, for example, a dedicated medicines lead ordered and reconciled people’s medicines and self-administration assessments were now in place for all people Records relating to the ordering and receipt of medicines did not provide a complete audit trail. It is good practice to ensure records include all stock received into the service, as well as quantities carried forward from the previous cycles to provide traceability and enable effective investigation of any discrepancies.

There still was not a robust process in place for medicines administration for people who were on social leave / out in the community. As a result, how this was managed varied depending on the staff member and was not always in line with good practice. The provider addressed this at the time of inspection, to ensure there was now consistent processes in place.

Staff received medicines training and had their competency assessed. However, the registered manager’s training and competency assessment had expired, we were therefore not assured of their competency to assess others.

The service reported good working relationships with the pharmacy providing medicines, in addition to with the community nursing team and learning disability team.