20 April 2022
During an inspection looking at part of the service
The Newlyn Residential Home provides the regulated activity accommodation for persons who require personal care to up to 13 people. The service provides support to older people, people living with dementia or a sensory impairment and people with a physical disability. At the time of our inspection there were six people using the service. The service is a large, converted property. Accommodation is arranged over two floors and there is a stair lift to assist people to get to the upper floor.
People’s experience of using this service and what we found
There was a lack of strong leadership at the service and despite a reduced number of people living at the service and the support of a manager, the provider had failed to make the required improvements to the service in the six months since our last inspection. Shortfalls at the service continued to place people at risk of harm.
The provider did not have a clear vision for the service or set of values for staff to work to. Checks had not been completed on some high risk areas of the service, such as diabetes care. Audits of the quality of other parts of the service had not identified the shortfalls we found. Robust systems were not in operation to gather and act on the views of people, relatives staff and other stakeholders. Where people had shared their views, these had not been used to improve the service. The provider did not have a detailed action plan in place to drive improvements and had relied on visiting professionals to identity shortfalls and guide them in how to address these.
People continued to be at risk because hazards to them had not been assessed and mitigated. Where risks had been identified action had not been consistently planned to protect them from harm. There was a lack of guidance of staff about how to keep people as safe and well as possible.
The management of medicines had improved, however further improvements were required. Medicines were not always returned safely and some medicines had not been returned. Again, we found medicines were not always stored at a safe temperature and there was a risk they would not be effective. Guidance was not in place around how to administer some when required medicines.
Effective systems were not in place to learn lessons when things went wrong. Accidents had been recorded and analysed. However, action had not been taken to reduce the risk of accidents happening again and they continued.
Staff deployment was not based on people’s needs and there were times when only one staff member was available to support people. Some staff had not completed practical training in core skills such as first aid and moving and handling and the provider had not assured themselves staff had the skills, they needed to keep people safe. Staff recruitment had improved, and the required checks of staff conduct and character had been completed.
Action had been taken to reduce the risk to people of the spread of infections including Covid-19. We observed staff were wearing masks correctly. People were supported to see visitors when and where they wanted. Staff knew how to identify safeguarding risks and the provider had reported any concerns to the local authority safeguarding team for their consideration.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
Following our inspection the provider closed the service.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was inadequate (published 13 January 2022). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.
Why we inspected
We carried out an unannounced focused inspection of this service on 14 October 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve medicines management, safe care and treatment, staff recruitment, learning lessons, infection prevention and control, records, checks and audits and obtaining and acting on feedback.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has not changed. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Newlyn Residential Home on our website at www.cqc.org.uk.
Enforcement
We have identified breaches in relation to safe care and treatment, medicines management, learning lessons, staff deployment, checks and audits, records and acting on feedback at this inspection.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
Special Measures
The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.