Newlands Hall

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 Inadequate. At this assessment the rating has improved 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 the legal regulation in relation to safe care and treatment at the service.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Since our last inspection the management of incident and accidents had improved. Lessons were learnt and audits carried out however, further embedding was required to ensure good practice. Staff were knowledgeable of how to keep people safe and knew what to do if they had a safeguarding concern. Staff said they would report to their senior, manager or go higher if nothing had been done.

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.

The provider worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. There were safeguarding systems, processes and practices to protect people from abuse, neglect, harassment and breaches of their dignity. However, further improvements were required as safeguarding audits were not robust. The safeguarding audits did not record when safeguarding incidents had been submitted, what the incidents were and the outcomes from any investigations to show oversight. We discussed this during our feedback with the provider.

Since our last inspection the management of incident and accidents had improved. Lessons were learnt and audits carried out however, further embedding was required to ensure good practice. Staff were knowledgeable of how to keep people safe and knew what to do if they had a safeguarding concern. Staff said they would report to their senior, manager or go higher if nothing had been done.

The provider did not always detect and control potential risks in the care environment. They did not always make sure facilities supported the delivery of safe care. During our walk around of the home we found areas were worn and in need of repair. For example, some of the flooring was coming away and wallpaper was hanging down from the ceiling. One fire guard was open as the plastic shield had come away. One relative said, “The outside garden area would benefit from a spruce up and more seating available.”

The home only had 1 bath and 1 shower for all service users. One relative said, “We would like to see improvements with the bathrooms as there is only 1 bath on the first floor and 1 shower on the ground floor.” Another relative said, “[Name] enjoys a shower but has to travel to the ground floor for this.” The provider informed us of their plans to increase the number of bathrooms and there was a renovation plan in place to improve areas of the home.

People had the assessed equipment in place which was set up according to their needs for example, air mattresses set on the correct settings, sensor mats and bed rails were in place.

All people living in the home had a personal emergency evacuation plan in place and staff knew how to evacuate people in the event of a fire. Fire drills were carried out with staff, however, the homes fire risk assessment was last completed in 2021 and had not been updated. We fed this back to the manager who agreed to take immediate action to address this.

Although we found no evidence of harm, this was a breach of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support and regular supervision. They worked together well to provide safe care that met people’s individual needs. The processes for recruitment of staff were safely managed. The provider had clear records to show the interview process, reference requests and use of the Disclosure and Barring System (DBS). Staff said there are enough staff. Staff comments included, “Sometimes seniors help and if more hands were needed the deputy manager also helps on the floor” and “There is enough staff on each shift. We have experienced staff who are able to manage the residents.” Staff were up to date with their supervision and the provider had a matrix which showed a planned date for upcoming supervisions. Staff had also completed their mandatory training.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. The home had an Infection prevention and control (IPC) action plan from the local authority following their visit in February 2025. During our inspection we asked for feedback from the local authority who said the provider had not completed all the actions. The bins outside were not covered to prevent against vermin. There was an old shed in the garden which was not safe and cleaning up was required to make the outside environment more desirable. Some areas of the home were not clean for example, areas of the kitchen had splash marks up the wall and some bathrooms were unclean. Within the kitchen most foods were labelled when opened however, some foods were in boxes and no dates were recorded as to when the food had been opened. We found other food in containers which was not labelled, and it was unclear what these were. The home had IPC stations in different areas which meant staff had access to aprons and gloves. Staff had received IPC training and during our inspection we observed staff using the equipment when needed.

Although we found no evidence of harm, this was a breach of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider did not always make sure that medicines and treatments were safe. The service did not have individual fire risk assessments in place for people who were prescribed paraffin-based skin products. The risk assessment in place was not individualised and a general assessment. Temperature records to ensure the safe storage of medicines were not completed in accordance with national guidance. This meant the provider could not demonstrate that medicines requiring refrigeration were safe for use. People’s preferences of how they wanted their medicines to be administered were not recorded.

Instructions for medicines which should be given at specific times were available. Detailed guidance specific to each person on how to administer medicines prescribed as and when people required them, known as “PRN” was available to staff.

Some people were prescribed a variable dose i.e. 1 or 2 tablets to be given when required at regular intervals. The time of administration had been recorded and the quantity given. This meant that records accurately reflected the treatment people had received.

Thickeners used to thicken fluids for people with swallowing problems were recorded when they had been used. The use of topical creams and ointments were recorded on the medicines administration records (MARs) and body maps were in place to show staff the site of application.

There were appropriate arrangements in place for the management of controlled drugs (medicines that require extra checks and special storage arrangements because of the potential for abuse). Records showed that staff completed regular balance checks in accordance with national guidance.

Staff told us they had completed a training and induction process for medicines management. Staff competencies were assessed regularly to make sure they had the necessary skills Managers and members of staff qualified to handle medicines regularly completed audits (checks) to make sure that procedures were followed. However, the shortfalls we found during the inspection had not been identified within those audits.

Although we found no evidence of harm, this was a breach of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.