Harvey Lane

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. At our last assessment we rated this key question Inadequate. At this assessment the rating has changed to Requires Improvement.

Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always investigate safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff recorded incidents on people’s individual care records using the Antecedent-Behaviour-Consequence model (ABC records). However, we found that these were inconsistently completed with some containing minimal details of incidents and actions that had been taken to de-escalate the situation. Some had been recorded as completed the day after the incident had occurred this meant that information recorded may not have been accurate.

An incident log was also in use which was being used to monitor ABC records and incidents; however, we found the same concerns in relation to the information recorded as were found on the ABC records themselves. This meant that incidents of concern were not always identified.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services.

The service had systems in place to support new people moving into the home. This included the service spending time with people in their previous home which they were familiar with and the person spending time at the service, so they were able to adjust to the new environment before moving in. One Healthcare professional spoken with told us, “The staff worked co-operatively following these sessions to the point that we were comfortable to discharge relatively quickly”.

The service worked well with local and specialised healthcare providers and had good communication systems in place, for example regular reviews with the GP practice.

The provider did not concentrate on protecting people’s right to live in safety or avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

We found that incidents of concern were not consistently recorded or identified using the systems in place. This meant that safeguarding concerns had not always been investigated or reported to the Local Authority.

Where required, people had Deprivation of Liberty Safeguards (Dols) in place or applied for. However, people's best interest forms and Mental Capacity Assessments required improvement to evidence people's involvement, appropriateness and review dates.

Systems and processes had not identified our findings during this assessment.

The provider did not always work well with people to understand and manage risks. Staff did

not always provide care to meet people’s needs that was safe.

The provider did not always work well with people to understand and manage risks.

We received mixed feedback from relatives One relative told us, “We are not involved in service assessments or care plans, but we would like more involvement”. While another relative told us, “I am involved in all [their] care plans.”

People had appropriate risk assessments in place and monitoring records had been implemented where needed for food and fluid intake, and bowel movement charts.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The service had systems in place to review the safety of the environment; however, we found that these were not always effective in identifying areas of concern. On the first day of our on-site visit, we found that external environmental concerns had not been risk assessed and risks had not been mitigated. For example, we observed paths in the garden to be covered with leaves and moss causing the path and steps to be extremely slippery, we observed people accessing the garden when they were distressed.

The Health and Safety audits had failed to identify that the service did not have a Lifting Operations and Lifting Equipment Regulations (LOLER) certificate in place for the specialist bath that is in place. LOLER ensures lifting equipment is safe for use and properly maintained. During the course of the assessment, the provider took action to rectify both concerns related to the external environment and the bath.

The provider did not always make sure that staff were qualified, skilled and experienced. They did not always make sure staff received effective support, supervision and development.

We found that not all staff had received a full induction when they started working for the

service.Not all staff had received Safeguarding Children Training and only 9 staff had completed the Care certificate. The Care certificate is a set of standards that health and social care workers are expected to meet. However, staff had received other appropriate training, which was needed to support people, such as positive behaviour support (PBS).One relative told us, “Some of the long-term staff are really good. They understand [their] needs, but maybe some of the new staff are not as well trained”.

We had concerns that not all staff had received competency checks for medication and finances by people appropriately trained. Competency checks provided did not always evidence the date they had been completed or who they had been completed by.

People received either 1:1 or 2:1 support and it was found that staffing levels were well planned and maintained. Staff told us that they felt they had enough time to support people.

The service followed a robust recruitment process.

The provider did not always assess or manage the risk of infection.

Systems were in place to monitor Infection Prevention and Control (IPC); however, they were not robust and did not efficiently identify risks. Audits had failed to identify the build-up of dust and dirt in the laundry room which we found on the first on-site visit. It had also not been identified that the tumble dryer was not vented outside causing the laundry room to be damp and steamy.

We also found that there was a lack of managerial oversight regarding food temperature recordings and the management of kitchen checks.

We raised the concerns found during the on-site visit with the service and they took immediate action to rectify the issues.

Staff had received IPC training, food hygiene and Control of Substances Hazardous to Health (COSHH) training. Staff had access to appropriate Personal Protective Equipment (PPE) and cleaning products were seen to be stored safely. Communal areas and bedrooms were clean.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medication records were well maintained and where people were prescribed when required medication, appropriate paperwork and records were in place. The service sought and followed appropriate guidance from health professionals. This included guidance on the use of antipsychotic medication to reduce the risk of over medicating people.

Controlled medication was stored safely and in-line with best practice, with each person prescribed a controlled medication having their own controlled medication book in place. All of the people in the service had received a medication review in the last year.