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 requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, premises and equipment and the way people’s medicines were managed.
 

This service scored 38 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not 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.

A review of some accidents and incidents had been implemented since our last inspection, however the reviews were unclear and there was no evidence of any learning taken from these reviews which could be used to improve care and reduce incidents.

Staff said they felt they would be listened to if they raised concerns, however there was a lack of full oversight of incidents and actions taken and repeat behaviours were not effectively tracked. Where an incident had been documented we did not see any evidence of appropriate investigation to understand behaviours and help to reduce similar incidents in the future.

In addition, several of the areas for improvement identified at our last inspection were still outstanding, highlighting that lessons had not been learned and a lack of learning culture within the home.
 

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. A more proactive approach was needed when contacting external services. For example, the blood glucose levels of a person with diabetes showed very large fluctuations. Records did not show evidence of the necessary referrals and escalations to investigate these levels and ensure the safety and wellbeing of this person.

In addition, where people had lost weight or their weight was recorded as obese, we did not see the necessary referrals needed to ensure people were being supported to be safe and well.

We did see evidence of referrals to the bladder and bowel service and the registered manager reported a good relationship with the local GP practice.
 

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.
Some staff understood signs of abuse and their responsibilities to safeguard people but training in this area was out of date for all staff.
People we spoke to mainly felt their relatives were safe in the home, however one did raise concerns about the safety of the premises saying, “I think the signing in should be stricter.”
Overall people and their families felt the staff kept their loved ones safe. One person told us, "(Relative) has been there a few years. It seems okay and it seems she is cared for.”
 

The provider did not work well with people to understand and manage risks. Staff did not 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 everyday tasks such as eating and dressing. However, people were not supported to mobilise to their potential. We observed people sat for extended periods of time in the same chair, without being given appropriate support or encouragement to mobilise. One person who received physiotherapy sessions weekly was not supported to mobilise outside of these sessions to encourage and support their mobility and wellbeing.
Risk assessments about care were not always person-centred, proportionate or regularly reviewed. Some risk assessments were created with inaccurate information which meant we could not be assured of the validity of them.
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. This was raised at the last inspection and the relevant risk assessment had not been put in place. In addition, there was not a risk assessment or management plan in place to ensure this person was being supported to exercise their freedom of choice to drink alcohol when they chose to.
There were several people living in the home who had diabetes, managed by their diet. We did not see any risk assessments in place for these people which meant we could not be assured that their diet and diabetes was being appropriately managed.
 

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.
When we arrived at the care home the front door was unlocked and we were able to walk straight into the home. This was a risk to the people living in the care home as there was the potential for anybody to be able to access it. A relative did raise concerns about this, saying, “Anyone can walk in and you don't know who you’ve got in the building.”

The premises were not designed and adapted in a way to meet the needs of the residents. The lounge area, while quite spacious had several chairs and became quite cramped when people had relatives visiting. There were large patio doors at the rear of the home which opened onto a large field used regularly by the public and dog walkers. At the last inspection it was raised that access to outdoor space was essential for the people living in the home and actions should be taken to utilise this space. However, at this inspection we found the space was still not being used and the views were obscured by a large bush.
People still did not have access to the outside or natural light which is essential for good quality of life and mental well being. Natural light is particularly important for people with dementia as it supports their orientation to the relevant time of day. This was fed back to the provider at the last inspection, however the same issues remained.

There was inadequate signage in the home including a lack of personalisation of people’s bedroom doors, which can be beneficial to help people to orientate around the home.
Checks of the building and environment were completed but where recommendations and action were required there was limited evidence that this has been completed including in relation to fire compliance and lifting equipment.
 

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.
Staff were mainly recruited safely but improvements to the induction process were required to ensure that all staff were confident and competent their role. A new home manager had been employed since our last inspection and records did not evidence an induction period. There were appropriate staffing levels however there was still limited delegation from the registered manager to senior staff and consequently staff were not supported to develop skills or reach their potential.
Rotas showed there were adequate staff members on shift each day. However, the member of staff who worked in the kitchen was on holiday when we visited the service. This was shown on the rota however the necessary adjustments to the rota had not been made which meant last minute changes were needed and a member of staff brought in.
People received continuity of care due to being supported by a regular staff team.
Supervisions had started to be scheduled more regularly and staff knew who they were accountable to.
 

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 and the home appeared generally clean. However, there was an odour within the home. We saw staff using PPE when supporting people to eat in the dining room and staff wiping down the dining room tables
There had been an improvement in the cleanliness of the home since our last inspection. However, some of the people living in the home had stains on their clothes which were older than that day.
Staff had received training in Infection Prevention Control (IPC) however this was now out of date and required renewing.
 

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.
At the last inspection we found that medicines were not managed safely and although some small improvement had been made overall, they were not sufficient to ensure that all medicines were managed safely.
People still did not always have their medicines administered safely or at the right times either because the prescribers’ and/or the manufacturers’ directions were not followed.
Records did not always show if medicines were given safely. For example, when medicines needed to be given at specific times or with a set time interval between doses, no records were made about the time those medicines were given.
The records about the use of prescribed thickener in drinks were poor and did not show they had been thickened to the correct consistency placing people at risk of choking.
When people were prescribed medicines to be taken ‘when required’ or with a choice of dose, the information recorded to support their administration was of variable quality. The information was still not detailed enough to ensure medicines prescribed ‘when required’ or with a choice of dose could be administered safely and consistently. Limited records were made to explain why these medicines had been administered or if they had been effective.
Diabetes was not managed safely. There was still 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.
Medicines were still not always stored at safe temperatures. The records showed that medicine had been stored above the room temperatures recommended by the manufacturers. The records about the fridge temperatures showed medicines in the fridge had been stored correctly. However, on the day of inspection, the fridge thermometer showed that they had been stored unsafely and staff demonstrated they did not know how to read the fridge temperatures. Waste medicines including flammable creams were stored in an electrical cupboard which posed a fire risk.
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.