Newhey Manor Residential Care Home

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 changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to the ways people’s medicines were managed and premises and equipment.
 

This service scored 47 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

There was a lack of a clear process to learn from accidents and incidents. Provider reports took place when a safeguarding concern was raised, however a more consistent approach was needed to ensure lessons were learned and a high standard of care was provided.

Staff said they felt they would be listened to if they raised concerns however incidents were not always documented on daily care notes which meant there was a lack of full oversight of incidents and actions taken and repeat behaviours could not be tracked and necessary interventions and reviews implemented.

Safety events and incidents were not routinely discussed in staff meetings or debriefs. There were no actions identified following incidents, and we did not see any examples of when safety incidents had been used as opportunities for learning.
 

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

There was not always a collaborative, joined-up approach to safety that involved the person, along with staff and other partners in their care. Referrals were made however follow up actions were not always taken. For example, one person had been given instructions from a physio but there was no evidence through documentation or observations that the person was doing the recommended exercises. The registered manager reported a good relationship with the local GP practice. They told us, “Staff are helpful and professional in their interaction with the practice. (Manager) is responsive to enquries for information.”

We did see information in the care files showing that documented visits from external healthcare professionals such as BARDOC and a DoLS (Deprivation of Liberty) assessor. However, a more proactive approach was needed when contacting an external service. For example, one person had been referred to the mental health service following agitated and aggressive behaviour, however little escalation took place to follow this up despite the person’s behaviours increasing and the risk he posed to others.
 

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.
There was a Safeguarding policy which appeared to be regularly reviewed. The staff we spoke to could identify some signs of abuse and they said they had Safeguarding training online and face to face. Staff said they would feel comfortable to raise any safeguarding concerns with the registered manager.
Safeguarding concerns were not always shared with CQC and there was no evidence to show that people were supported to understand their human rights and we did not see any evidence of Mental Capacity Assessments in people’s care plans.
 

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.
Staff showed care to the people they looked after and supported them to perform every day tasks such as eating and dressing. However, people were not enabled to mobilise to their potential. One person’s care file documented that they could walk with assistance however we observed him being transferred in a wheelchair to go to the toilet and back to their chair and they were not supported to stand or walk.
The registered manager explained how he supported positive risk taking by trying to encourage people to walk as much as they could with minimum support and avoid wheelchairs when available to stand even for a short period. However, we did not see evidence of this in care notes or through observations.
Risk assessments about care were not always person-centred, proportionate or regularly reviewed. One person who liked to order items via the internet had his deliveries intercepted by staff however there was no risk assessment in place for this to ensure he was being allowed to have freedom to order items in a safe way.
We saw people communicating their needs, emotions or distress and people were supported, for example one person who said they were scared was supported by a member of staff who came and sat with them, talked to them and was able to support them to move to the lounge where they became much more relaxed. However, this was not always consistent or managed in a way that protected people’s dignity. Another person had their evening meal brought to them in the lounge and placed on a table which was too low, their knife and fork were placed the wrong way around and although they were left to eat independently this was not done in a way which enabled them effectively.
 

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The premises were not designed and adapted in a way to meet the needs of the residents. The dining area could not comfortably accommodate all the people in the home, which meant that some residents stayed in their chairs in the lounge and ate from tables. These tables were too low, meaning people had to lean forwards or pick their plates and bowls up. The dining experience was often undignified and uncomfortable.
The lounge area, whilst quite spacious, was cluttered with several chairs and plastic boxes. A small area had been sectioned off during covid and was still in situ. It was unclear what this was now used for on a daily basis. There were large patio doors at the rear of the home which opened out onto a large field used by dog walkers mainly. This area was not used by the home and the views to the field were obscured by a large bush.
The lift could not accommodate a stretcher which meant that a person returning from hospital had to be hoisted in the dining area into a wheelchair. As there were no curtains or screens this was done in full view of all the other people in the home and the person’s dignity was not adequately preserved.
People did not have access to the outside or natural light, which is essential for a good quality of life, particularly for those with dementia. In addition, there were three clocks in the lounge which all showed different and incorrect times. The clocks, combined with the lack of access to natural light would make it very difficult to orientate to the correct time of day, particularly for those people with dementia.
There was inadequate signage in the home; we saw a person who was mobile struggling to orientate around the home. One person who spent all their time in their bedroom said a male resident often came into her room, which she was not comfortable with. The staff said he often walked around trying to find his own bedroom. Nothing had been explored with the person as to what could be put in place to help them find their room independently.
The environment was safe with the necessary checks conducted by the registered manager including electricity, legionella and fire safety checks. We contacted the fire service following our first day on site due to the over-use of extension leads and they scheduled a visit to the home.
Staff said they would check equipment before using it and report any problems to the registered manager. They also said that they had recently had some training in using equipment in the event of a fire.
We saw evidence of walk arounds conducted by the registered manager and audits for equipment such as bed mattresses. The feedback collected from residents showed that 100% said the comfort in their room was good or excellent.
 

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.
The recruitment practices were safe but more evidence of appropriate interview questions was needed to give assurances that all staff were suitably experienced, competent and able to carry out their role. There was no structured shadowing and induction period for new starters and although there was evidence of regular training, one member of staff had been employed for a few months without completing training in all the necessary relevant training for their role. There were appropriate staffing levels however there was no delegation from the registered manager to senior staff and consequently staff were not supported to develop skills or reach their potential.

While there was evidence of supervisions and competency checks, these were not consistent. The registered manager said he encouraged his staff to complete qualifications and offered financial incentives but we did not see any evidence of this.

Training was scheduled after each monthly team meeting which was documented and staff signed to say they had attended.

Rotas showed there were adequate staff members on shift each day and changes had been made to the start time of the day shift to ensure there was enough cover in the mornings. However, the rotas did not always reflect current staffing situation, for example a domestic staff member had been off for weeks but this was not reflected in the rota. People did experience continuity of care due to being supported by a regular staff team.
 

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.
The service employed domestic staff who we observed cleaning during our visits. However, there was a strong smell upon entering the home and the hand sanitiser in the entrance area was empty. The staff who we spoke to said they felt the home was clean and they were not aware of any recent outbreaks or infections. We saw staff using PPE when supporting people to eat in the dining room and staff wiping down the dining room tables. Residents rated the home’s cleanliness as excellent or good.

There were flies in the lounge area, stained cushions and people were drinking tea out of stained mugs. One of the walls in the lounge was also stained and the floors in the corridor were sticky, however people mostly looked clean and had suitable clothing on. There was evidence to show that walk arounds were conducted by the registered manager and observations included “The cleaner started at 9am mopped all corridors” and “The home was clean and tidy, staff adhering to wearing aprons in the dining room and PPE with personal care”.
When walking around the home we did see staff changing the bedding in people’s bedrooms and tables being wiped down in the dining room. However, cleaning appeared to be on quite a basic level, with dust and dead spiders visible on windowsills.
 

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.
People did not always have their medicines administered safely or at the right times either because the prescribers’ and manufacturers’ directions were not followed or because there were no clear directions to follow. One person was unable to have doses of two of their prescribed medicines for 5 and 6 days because they were out of stock, which placed their health at risk. When people were prescribed medicines to be taken ‘when required’ or with a choice of dose, the protocols to support their administration were not detailed enough to ensure they could be administered safely and consistently.
People’s creams were not always managed safely because they were not always applied as prescribed. People’s diabetes was not managed safely. One person had their insulin doses changed but the records showed they were given the old dose for 4 days. The blood sugar testing strips were out of date which meant their blood sugar level reading may not have been accurate. There was no information recorded about safe ranges of blood sugar levels or the actions that staff should take when blood sugar levels were too high or low.
Records about medicines were not always accurate. Staff signed the records to confirm they had given medicines before they had given them to people. Medicines were not always stored at safe temperatures. The records showed that for 2-week period medicines had been stored at temperatures which were higher than recommended by manufacturers. Medicines that required cold storage, including insulin, were stored at temperatures colder than the manufacturers advised. There was no record to show that any checks had been made to ensure the medicines were fit for use. Waste medicines were not stored safely in line with current guidance. We found no evidence that people were harmed at the time of the assessment because the harm is not always immediate. However, people were placed at increased risk of harm by not managing medicines safely.