Newhaven

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 and were in receipt of safe care and treatment. At our last assessment we rated this key question good. At this assessment the rating was rated as inadequate.

This meant there were widespread and significant shortfalls in providing safe care and treatment due to the absence of a governance processes and safeguarding processes.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The feedback from people and families was positive about their experiences at Newhaven. We observed staff engaging with people in meaningful ways that showed staff understood people's preferences and communication needs. When we spoke to staff, they knew people well and could give examples of how they supported people in person centred ways such as people's preferences, how they like to spend their time at Newhaven, how people liked to dress and appear, favourite meals and drinks and places people liked visit including visits to the local shops. We observed people receiving visitors and using the dining room as this was their preference. We observed family members taking their loved ones out for an evening meal and staff were observed to be engaging with families and supporting visits.

The provider did not have a proactive learning culture embedded in the service. They did not investigate or report safety events, the provider was not aware that certain events were reportable. Lessons were not learnt to continually identify and embed good practice due the lack of oversight and assurance from processes and governance systems. The registered manger and staff told us they had a culture that was open and supportive of people. The registered manager said action was taken to manage risks, however, acknowledged there were no systems or processes to record, review and learn from incidents that have or may occur.

The provider did not work well with people and health system partners to establish and maintain safe systems of care, preadmission assessments and initial assessments were not available in people's care files and information regarding people’s recent and past health appointments were not present in the care files. The provider did not make sure there was continuity of care if people were to go to hospital due to the absence of hospital passports.

The provider did not have safe systems and processes to oversee their safeguarding practices, the safeguarding policy was not robust to support how to work well with people and healthcare partners to understand what being safe meant to people and how to achieve that. They did not concentrate on improving people’s lives or protecting their rights through quality monitoring processes. The provider did not share concerns quickly and appropriately when required. Staff did not always receive safeguarding training, deprivation of liberty safeguards training, consent and mental capacity act training and the compliance was below 50% for staff.

The provider did not work well with people to understand and manage risks. Care plans were out of date and not reviewed regularly with people who had capacity. Care plans were not person centred and contained limited guidance for staff on how to maintain people's safety. For example, we saw one person who had a percutaneous endoscopic gastrostomy (PEG), they did not have a detailed care plan or risk assessment in place. One person who had been assessed as having choking risk factors had instruction from the speech and language therapy team (SALT) on how to prepare food and measures to take to reduce the risk of choking. This information was not in a risk assessments or care plans. One person had been assessed as being a high falls risk, however, there was no risk assessments or measures identified to mitigate the risk of falls. One person was identified as being at risk when travelling in a car, however, there was no risk assessment or measures identified to mitigate the risks of travelling in a car. Care plans did not hold dates when people were last at the opticians, receiving hearing tests, medication reviews and dental health appointments. Leaders did not undertake audits of care plans and did not know if risk assessments were completed accurately, in the right timescales or kept people safe. There were no clear systems or oversight of risk assessments processes.

The provider did not detect and control potential risks in the environment. They did not always make sure equipment, and facilities supported the delivery of safe care. The provider did not have environmental risk assessments to mitigate risks. The provider did not have a legionella risk assessment and water sampling certification. Tests had not been recorded appropriately when undertaking weekly fire alarm checks and carbon monoxide alarm tests. The stair lift certification for servicing was not up to date. The provider did not have an auditing process in place for oversight to improve safety and ensure health and safety compliance.

The provider failed to ensure staff received training relevant to their roles. We found staff had not always undertaken the provider's mandatory training. For example, only 50% of staff completed the following courses, safeguarding, epilepsy, role of the care worker, infection control and the Deprivation of Liberty Safeguards training was only completed by 4 staff.

Staff training compliance was low and the feedback from some staff stated they did not receive regular supervisions. Staff competence was not assessed in relation to moving and handling of people and the practical training required was not allocated. Training courses in relation to oral hygiene, dysphagia, percutaneous endoscopic gastronomy (PEG) to include medication administration and competency assessment, managing risk and data protection, staff had not been allocated these courses. Peoples care plans did not reflect when people receive one to one support and did not describe how the staff’s skills and experience had been matched to the needs of the person to enable people to work towards and achieve their aspirations and potential.

The provider failed to ensure safe infection prevention and control. The provider did not implement an auditing and quality assurance process to monitor and check the cleanliness of the service to promote infection prevention and control management. The provider had not completed or considered the need to complete a risk assessment for legionella disease. The environment in the kitchen was of substandard hygiene standards. Cleaning schedules were not in place. The communal bathrooms stored personal items and toiletries. Several mattresses required deep cleaning; this was actioned by staff immediately upon reporting. Staff training for infection prevention and control and hand hygiene was 50% compliance.

People and relatives did not identify to us any problems with medicines and told us they got their medicines on time. However, people were not aware that medicines were managed unsafely which put them at risk. The medication policy and procedure was for a home care agency and did not reflect processes and procedures that was in place at Newhaven. The provider did not make sure medicines and treatments were safe and met people’s needs. People were not involved in planning and annual medication reviews with the GP were not reflected in care plans. There was an absence of medication risk assessments for people. ‘When required’ medication (PRN) was not reflected on a PRN protocol for people who did not have capacity. We found medicated creams were required to be kept refrigerated kept in bedrooms at room temperature. We found medicated creams, nasal sprays and medication liquids not labelled when opened and not used within the time frame as directed by the manufacturer. One person used transdermal medicated patches which required to be rotated on the body for each application, the provider did not ensure a rotation chart was in place. We observed medication equipment requiring a deep clean. Medication was found to have been unsafely used for another person whom it was not prescribed for, a safeguarding referral was made by the inspector. The provider did not ensure staff received medication competency assessments to include topical medication administration and the use of prescribed thickening agents for food and drink. The provider did not have an auditing process to monitor and ensure medicine management was safe.