Newlands Hall

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant some improvements had been made but the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation in relation to governance at the service.

This service scored 57 (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 had a shared vision and culture, but improvement was required to ensure it was embedded throughout the service. At our last 5 inspections the provider has been rated requires improvement or inadequate therefore, the provider needs to demonstrate that there is a continuous approach to improving care.

Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. Following our last inspection the provider had implemented further governance checks however we identified issues where improvements were required to ensure their auditing systems were robust. During the last 5 inspections the home has been rated requires improvement or inadequate and whilst leaders had developed their governance systems, they had not had time to embed them fully and be effective.

People and their relatives told us the home was well managed, and they felt well cared for, comments included, “It can be a thankless job at times, but [Registered manager] is very good” and “[Registered manager] appears to know the staff and residents very well.”

Staff told us, “We do have regular meetings with the directors, management, general meetings and we provide feedback. We do staff surveys, friend and families surveys” and “They (management) are approachable, always available whenever we need them for anything or for any concerns, they are always available.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider carried out surveys from people, relatives and staff to gather feedback. People, relatives and staff all told us they felt able to raise any concerns with the provider and felt these would be addressed. All the relatives we spoke with said they could speak about the care their relatives received very easily and that minor changes have been made quickly. Staff told us they felt able to speak up and comments included, “If something wrong is happening or you see something wrong, you can blow the whistle. If something is not going right and you don’t want to go to the managers, you go to the directors. Directors come in and do one to one meetings.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The service had a diverse workforce and an equalities policy in place. Staff we spoke with told is they were treated fairly. One staff member said, “Management always support us.”

The provider did not always have clear systems of good governance. At our last inspection we found audits were not robust. At this inspection we found the provider had improved however, there was still work needed to ensure the service provided good care. For example, safeguarding audits were carried out but there was no process to see how issues identified had been followed up within the audit process. The fire safety audits had not identified that the fire risk assessment was last completed in 2021. The medication audits had not highlighted the issues we found on our inspection.

Although we found no evidence of harm, this was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. However, in some instances actions had not always been completed in a timely manner. For example, actions identified in an infection control audit had not been completed following a review from the local authority.

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.