Newlands Hall

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

The service not effective. We identified a breach of regulation around how people were supported to maintain good nutrition and hydration and around how the service applied the principles of the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). People were not supported to have access to high quality, nutritionally balanced meals. Several people had lost weight and the provider had failed to act on this to ensure they were protected from the risks of malnutrition. The service had not applied the principles of the Mental Capacity Act and DoLS appropriately. This means people were deprived of their liberties or had decisions made on their behalf without proper processes first taking place to determine if this was in their best interests.

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.

People told us they were happy their care and treatment. One person said, “I am comfortable here.”

The registered manager told us staff have an induction and training refreshers to ensure they have the right qualifications and experience to assess and meet peoples needs effectively. However, we found evidence that training in some subjects was out of date and staff had not received refresher training.

We found effective systems were not in place to assess, monitor and mitigate risks to service users and keep them safe. We identified some service users’ needs were not met in respect of management of their diabetes, falls, skin integrity, weight loss and continence. This put people at significant risk of being harmed and their health and wellbeing deteriorating. For example, one person was at risk of developing a pressure ulcer but there was no skin integrity risk assessment in place to guide staff on how to reduce risks to them and their care plan did not include sufficient information for staff. This person should have been repositioned every 4 hours to reduce the risk of pressure damage but records did not demonstrate this happened consistently and this placed the person at risk of harm. There was no care planning in place around this person's diabetes or the support they required with catheter care. This placed them at risk of harm.

Prior to the assessment visit, a relative told us they were not involved in decisions made about their family member's care despite holding the relevant legal entitlement to this involvement. They told us restrictions had been placed on their family member and changes made to their care without input from them. Their complaints prompted this assessment. We substantiated this part of the complaint at our visits.

The registered manager told us that they plan and deliver people’s care and treatment with people and their relatives. However, there was no evidence to demonstrate that people or their families had been involved in this process. Care plans lacked personal preferences and detail.

There was no evidence that people or their relatives were involved in care planning. One relative told us they had not been involved in the planning of care or decisions made on their relatives behalf, despite holding the required legal entitlement to be involved in all decision making. Care plans lacked personal preferences and detail including what was important to each individual.

People told us they were able to access their GP and other healthcare professionals. One person said, “They have got a doctor out and [family member] was rushed into hospital when they rung."

The registered manager told us they work effectively across teams and services to support people. However, evidence we collected during our assessment showed they had not made all referrals required to healthcare professionals . This meant people may not always receive the input they required to promote their health and welfare.

A healthcare professional told us they had raised concerns about one persons continence care and changes that were required but no action had been taken. They also told us that equipment was not always available with regard to the care and monitoring of one person's diabetes. They told us they had requested that the service contact the GP for one person due to a deterioration in their health but this had not happened.

During our assessment we identified that 5 people had experienced substantial weight loss. Despite this, the registered manager had not made a GP or dietician referral. This meant these people were placed at risk of further weight loss and malnutrition.

One relative told us, "[Family member] loves the food." A person using the service said, “The food is very, very nice”. However, another relative told us they had to come in daily to ensure their relative was supported to eat. Another relative complained that their family member was not supported appropriately with food.

The registered manager told us that they routinely monitor people’s care and treatment to support people to manage their health and wellbeing. However, we found no evidence that demonstrated this was happening. We found gaps in people's food and fluid intake records that had not been identified in audits. The registered manager and provider had failed to identify that 5 people had substantial weight loss.

During our assessment, we observed that people were not being offered suitable and nutritious food and hydration which was adequate to sustain life and good health. The portions sizes were small and not nutritionally balanced. No snacks or extra foods were offered between the breakfast and lunchtime meal, even where people had a low weight or were losing weight.

We found substantial weight loss for 5 service users. We discussed the weight loss with the registered manager, as there was nothing in the records to demonstrate this had been acknowledged and investigated. The registered manager was unaware of the weight loss and had therefore not taken action to refer these people to the GP or dietician. This demonstrated there were ineffective systems and processes in place to identify weight loss and there was insufficient oversight. This placed people at risk of malnutrition.

Where people were having their food intake recorded, we found there were gaps on food charts and this had not been identified by the registered manager.

One person said, “They absolutely understand [family member's] needs." A person using the service said, “I am always well looked after." However, one relative who complained to us about the service stated that their relative's care had not been reviewed or updated when their needs changed and this meant they received the wrong care which could have placed them at risk of harm.

The registered manager told us that they routinely monitor people’s care and treatment to continuously improve it and ensure that outcomes are positive and consistent. However, care plan and risk assessment reviews, updates and audits did not identify issues identified in our assessment. The service failed to ensure there were adequate systems to assess, monitor and improve the quality and safety of services provided, including monitoring people’s care and treatment to continuously improve it. This meant the provider could not demonstrate what the registered manager told us was correct.

Care plans and risk assessments were not always reviewed and updated where people's needs had changed. This placed people at risk of receiving care which was not safe for them. Records in place were not always clear about the care people required and how staff could meet their needs safely.

One relative told us that restrictions were placed on their family member without this being discussed or agreed with them. Evidence collected substantiated what the relative told us. A person using the service said, “I can choose what I want to do.”

The registered manager told us that they tell people about their rights around consent. However, processes were not always in place to ensure care and treatment was provided with the consent of the relevant person, failing to ensure that the principles of the Mental Capacity Act 2005 were complied with. The registered manager did not demonstrate a good knowledge of consent procedures and best interests decision making processes.

Restrictions had been placed on people who lacked capacity to consent to their implementation. Correct procedures under the Mental Capacity Act had not been followed before these restrictions were implemented, rendering them unlawful. Mental capacity assessments specific to the decision were not always in place to ensure the implementation of the restrictions was in line with legislation.

For example, one person had bed rails in place. A Deprivation of Liberty Safeguards (DoLs) had previously been in place but had expired on 17 May 2024, meaning there was not the appropriate paperwork to place restrictions on this person. There was no decision specific Mental Capacity Assessment in place around bed rails and an appropriate best Interest's decision making process had not been followed.

Another person had a sensor mat in place but their DoLS had expired and this had not been identified. There was no decision specific mental capacity assessment around the use of the sensor mat and an appropriate best interests decision making process had not been followed.