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

The service was not safe, and people were placed at risk of harm. We found breaches of regulation around safe care and treatment and safeguarding. The service failed to identify, plan for and effectively manage risks to people. This placed people at the ongoing risk of harm. The service also failed to ensure people’s medicines were managed safely and administered in line with the instructions of the prescriber. The provider failed to operate systems to identify and investigate possible abuse. The provider had not identified these issues independently and taken action to protect people.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

During our assessment visits, people we spoke with did not raise any concerns. However, this assessment was prompted by a complaint made by a relative about their family member's care. During the assessment visit, we were able to substantiate the contents of this complaint. The registered manager had failed to implement any actions in response to the complaint before our visit, which meant the provider could not demonstrate there was a suitable learning culture.

The registered manager told us they have an open and honest culture, and they acted on and investigated any safety concerns reported to them. Staff told us they could raise concerns around safety if required. One staff member told us “Yes, the manager is approachable. We can go to the manager with any issues or concerns.” However, we found evidence that contradicted what the registered manager told us and the registered manager failed to take accountability with regards to a complaint made by relatives about a persons care. We substantiated the contents of this complaint during our inspection, but the registered manager had failed to implement changes as a result of the complaint before our visit.

There were insufficient processes in place to ensure that incidents and accidents were learned from and measures implemented to reduce the risk of repeat events. We found that falls were recorded on a central system. However, when people had multiple falls their risk assessment had not been updated to include guidance to staff on how to mitigate future risks. Care plans did not always reflect the increased risk or need for action to manage the risk of future falls. This placed people at risk of harm as a result of repeated falls.

The registered manager told us that there were systems and processes in place to manage the transition into the service safely and that a pre-assessment was completed. However, we found effective systems were not in place to assess, monitor and mitigate risks to service users and keep them safe. For example, the pre-assessment failed to identify risks to one person which were then not managed by the service effectively.

During one of our site visits a health professional raised concerns with us in relation to how one person's continence needs were not currently been managed well and felt this was potentially impacting and preventing the persons pressure ulcer from healing . In response to this the registered manager told us that the continence team would not provide any support and the service would not be able to fund the continence aids required. The provider however, had taken no further action to resolve this issue and it had not been identified they would not be able to meet this persons continence needs as part of a pre-assessment. This placed the person at risk of ongoing harm.

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.

During this inspection we spoke to 6 people and 4 relatives.

One person told us they felt safe and commented, “Absolutely safe, all the doors are locked, and the staff have the key codes.” Another person told us, “Yes I feel safe."

The registered manager told us they were clear on their responsibilities and duty to identify and report any safeguarding concerns. However, we found evidence that the management were not completing investigations and safeguarding referrals when required. Staff we spoke to knew how to report abuse. They told us “I would report any incidents that happen, and I would report everything to management on the system and verbally”.

We observed that staff were raising and documenting concerns such as unexplained bruising. However, there had been no investigation into where these injuries had come from. The registered manager did not have oversight of this information, and this was not picked up in any audits completed by management.

The service had a safeguarding policy in place. However, safe and effective safeguarding practices were not in place to ensure people were protected from harm or abuse. Where unexplained bruising was documented by staff, this was not investigated or reported by the registered manager. During our assessment inspectors saw documents identifying 4 people with bruising/skin tears which were unexplained. There had been no investigation into where these injuries had come from. The registered manager did not have oversight of this information, and this was not picked up in any audits completed by management or provider. The registered manager told inspectors that one person was prone to bruising and an investigation was not needed as they had done this in April 2024. There was no documentation in place to justify this in the person's care plans or risk assessment, and this is not safe practice. Some staff members required updates to their safeguarding training as this was overdue on the provider's training matrix.

People told us they felt safe with the care received.

One person said, “I have had no falls. I just had a stumble but I was alright” and a relative commented, “[Family member] has been here eleven months and was it difficult at first but has settled down now. They have not had any accidents or falls."

Managers and staff demonstrated a good understanding of how people's needs and risks should be managed. Some comments from staff were, “The care plans are updated if care needs change in any way” and “We review care plans and assessments every month but if needs change we review it straight away and update it”. However, during this assessment we found examples where risk assessments and records of care provided required further detail and this had not been identified in reviews.

We observed 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.

Risks to people were not always identified or managed well. We found examples where risk assessments and records of care provided required further detail. This placed people at risk of harm or injury. For example, one person had a pressure ulcer and we found there was no risk assessment in place, nor was the care plan sufficiently detailed to guide staff on how to support this person with wound healing. Their care plan did state they should be repositioned every 2 hours. However, we found repositioning records did not demonstrate they were being repositioned at this frequency consistently. This placed the them at risk of wound deterioration. In addition, this persons care plan was unclear with regard to the support they required with mobilising safely. This placed the person at risk of harm while mobilising. Where accidents and incidents had occurred, these were not always followed up or reviewed, nor did investigations lead to review of care records and risk assessments for people.

No concerns were raised around the environment. One person said, "Oh yes, I have a nice room”.

The registered manager told us the service detected and controlled risks in the care environment. However, on observation staff could not identify one person's assigned sling for mobilising. Another person had a sling in their room that belonged to another person who had died. When we discussed this with the senior carer on shift, they told us that staff muddle up people's slings, and they confirmed to us that staff are using slings for people that belonged to different person. During our inspection we identified one person had unexplained bruising. When we asked the service to investigate this, the person said this happened when a staff member caught their leg when assisting them with the hoist. This meant we were not assured that people were supported to mobilise in a safe way.

During the assessment, inspectors observed 2 bathrooms which were being used as storage rooms and not bathrooms. These rooms contained hazards such as unused equipment and cleaning products. These rooms had been left unlocked and were therefore accessible to people who could be placed at risk of harm. In one corridor on the bottom floor, inspectors observed a tall cabinet with a glass door. This had been moved there so renovation work could take place in the lounge. The glass door was open, and the cabinet was left free standing so there was a risk it could have fallen onto a person and caused harm.

The service had a risk management policy and procedure in place and a renovation plan. During the assessment, renovation work was taking place in the home and inspectors found that risks to service users were not identified or managed effectively.

The service did not have an effective system in place to monitor the documentation required for use in an emergency. Inspectors found most people did not have an up-to-date Personal Emergency Evacuation Plan (PEEP); this placed people at increased risk in the event of a fire. Health and safety audits by the manager and provider had not identified this.

The PEEP grab file was not up to date and there was a considerable number of people who either did not have a PEEP or did not have the correct details on their PEEP. The grab file also contained PEEPs for people who no longer lived at the service. Out of the 25 people living at the service, 3 had accurate PEEPs, 5 did not have their room number on the PEEP and the other 17 people did not have PEEPs in place. This placed people at risk in the event of a fire.

We received mixed feedback around safe and effective staffing. One person said, “Yes, there seems to be plenty of staff." However, another person said, “They do very well but they could do with a couple more staff."

We received mixed feedback in relation to staffing levels. Staff told us “There are not enough staff on shift, and this has been brought up to management, but nothing has happened. With the care needs of our residents, having another staff member would make a huge difference.”

During our assessment we observed that staffing levels appeared to be sufficient. There was an activity coordinator who was chatting with people and did a quiz in the lounge. On the second site visit a new person had been admitted and was very distressed. Staff did not seem to know how to address the person's distressed state. They were distressed for most of our visit, with staff not intervening and attempting to provide comfort to them.

Policies and procedures were in place for safe and effective staffing. These were not always been followed. Staff were not always recruited safely and we saw evidence of gaps in references and employment history.

The provider's training matrix identified some staffs mandatory training had expired. Staff told us that training was online and that they would benefit from a more robust in-house training program. Comments included "Proper in house training would be beneficial for us. Online training isn’t as good” and “I think we would benefit from some face to face first aid training."

The management team were clear on infection prevention and control procedures and their responsibility to provide personal protective equipment (PPE). However, we found no evidence of infection control audits. Staff told us they were aware of their responsibility to wear PPE.

We observed staff wearing personal protective equipment correctly. We observed a cleaning schedule in a downstairs toilet that was not fully completed and had gaps in. This had not been identified by the management team.

There was an infection control policy and process in place. The management team were clear on the infection, prevention and control measures. However, there was no system in place to monitor cleanliness or infection control procedures. We identified gaps in one cleaning schedule which had not been identified by the management as there was no system in place to audit these. This meant the provider could not demonstrate shortfalls in cleaning would be consistently identified.

Most people did not raise any concerns with how their medication was managed. One person said, “They give me my medication." Another person commented, “I do have medication, but I don’t know what it is." However, a relative complained to us during our assessment and stated their relative had been given medicines at the wrong time of day.

Managers told us they were aware of their medication management responsibilities and had a medication policy in place. However, systems were not in place to ensure the proper and safe management of medicines, which placed people at risk of harm.

Protocols were not always in place for 'as and when required' medicines (PRN). Medication care plans were also not specific or detailed with this information, meaning staff did not have appropriate instructions and information on how and when to administer medicines prescribed to be taken as required. Whilst there was no evidence of overuse of these medications, there was a risk that staff could administer PRN medicines inappropriately due to a lack of guidance about their use.

Time Specific medications were not always given as per prescriber’s instructions. We found 4 people had a medicine to be administered 30-60 minutes before food. However, this was not included in the early morning medication round, meaning 4 service users were given this medicine later in the morning with or after food. This could compromise the medicines effectiveness.

Topical Medication Administration Record (TMARS) were not always completed consistently. TMARS contained gaps in administration. Therefore, the service could not demonstrate that people were receiving their creams as per prescriber’s instructions. This could compromise their skin integrity.

The medication policy stated that a section with persons full name, date of birth, GP and allergies should be included on the front sheet, and that it was good practice to include picture of the person. We found this was not always being complied with. Some service users did not have a photo or allergen information on the front sheet. There was no evidence that a second staff member had checked the entries were correct on handwritten MARs which meant staff were not following the service's policy. This increased the risk of medicine errors.