Newton Hall Residential Home

We found 3 breaches of the legal requirements in relation to safe care and treatment, infection control and prevention, consent to care, medicine, staffing and good governance.

The provider did not have effective governance systems in place to monitor, assess and improve the quality and safety of the service. Quality assurance processes had not consistently identified or addressed concerns relating to care records, environmental safety, staff support and compliance with legal requirements. As a result, opportunities to identify risks and implement timely improvements had been missed.

There were systems in place to assess risks to people and ways to reduce them, but these did not always include all risks affecting people to ensure risk mitigation was in place, and guidance for staff was not readily available. The quality of risk assessments varied, with some risks being detailed whilst others were not. Records were not always accurate and/or complete. This was particularly important as the provider used agency staff who required accurate guidance to enable them to provide care which was effective and safe.

Documentation reviewed indicated consent was not consistently obtained and recorded for some people who lacked capacity. This meant there was insufficient evidence to assure care, and treatment decisions had been made in accordance with individuals' preferences, best interests, and relevant legislation.

Records showed people received their medicines as prescribed, however, we noted some gaps in the medication administration records which lacked crucial information about how to administer some medications. Written guidance for staff about some medicines prescribed for occasional use was not always available.

The environment was not always maintained well, so people were not always spending time in pleasant environment. People were not always protected from the risk of infection.

There was a range of activities available throughout the day, and everyone had equal access to participate in the opportunities provided.

Most family members spoke positively about the service and expressed high levels of satisfaction with the quality of care provided, as well as the leadership and management of the home. Family members and friends were welcome to visit at any time without the need for prior arrangement or notice.

We asked the provider for an action plan in response to the concerns found at this assessment.