Hall Lane Resource Centre (Respite Care, Short Breaks Service)

Hall Lane Resource Centre (Respite Care, Short Breaks Service) (Hall Lane) is a residential care home providing short breaks and longer-term placements to people with a learning disability, and/or autism. The service is registered to support to up to 10 people at a time. At the time of our inspection there were between five and 10 people staying at Hall Lane. The service was accessed by up to 94 people.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This includes help with tasks related to personal hygiene and eating. Where people receive such support, we also consider any wider social care provided.

The service was larger than most domestic style properties and accommodated up to 10 people. This is larger than current best practice guidance. The service was also located within premises that set it apart from normal domestic properties. It was based on part of the first floor of a larger council building that also contained council offices and a day centre. The main entrance to the premises was via a reception area for the whole building.

People’s experience of using this service and what we found

The provider had recognised and acted to address potential safeguarding concerns they had found in the service. Staff and people using the service spoke about there now being a ‘better atmosphere’ in the service and they told us they would feel comfortable raising any concerns they had. Whilst staff understood how to keep people staying at the service safe, robust risk assessments were not always in place.

Staff were able to meet people’s dietary needs and preferences. However, other improvements since our last inspection relating to good food hygiene practices had not been maintained. The provider had checked staff were competent and able to meet people’s needs. Training was ongoing, particularly as a large proportion of the support staff had been recently recruited.

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. However, the policies and systems in the service did not always support this practice.

The service didn’t always apply the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

The outcomes for people did not always fully reflect the principles and values of Registering the Right Support for the following reasons; The service supported people for both short breaks and longer-term ‘emergency placements’ that we were told were not always time limited and were not always a good ‘match’ with other people using the service. The service was located in a building that potentially isolated people from the rest of the community.

The service had relied heavily on agency staff, although they ensured that the same members of agency staff were used when possible. The service had recently recruited more staff to permanent positions and people using the service and their families were positive about the kind and considerate approach of staff. Carers/relatives told us communication with staff in the service was good, and that they provided them with useful information.

People’s care plans were person-centred and noted people’s preferences. However, they sometimes lacked detail about how the service would meet particular needs and contained little information about any goals or aspirations people might have. Whilst people felt involved in care planning, the provider’s systems for reviewing people’s care annually and prior to each stay had not been followed consistently. We have made a recommendation in relation to person-centred care planning.

Due to priorities relating to staff recruitment and safeguarding, some of the systems and processes for monitoring and improving the quality and safety of the service had not been maintained. Staff told us they worked well as a team and felt there was a positive and improving culture within the service.

The Secretary of State has asked the Care Quality Commission (CQC) to conduct a thematic review and to make recommendations about the use of restrictive interventions in settings that provide care for people with or who might have mental health problems, learning disabilities and/or autism. Thematic reviews look in-depth at specific issues concerning quality of care across the health and social care sectors. They expand our understanding of both good and poor practice and of the potential drivers of improvement.

As part of thematic review, we carried out a survey with the registered manager at this inspection. This considered whether the service used any restrictive intervention practices (restraint, seclusion and segregation) when supporting people. The service used positive behaviour support principles to support people in the least restrictive way. No restrictive intervention practices were used.

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 requires improvement (published 09 August 2018). At our last inspection we found one breach of the regulations. The provider completed an action plan to tell us what they would do and by when to improve. At this inspection we found improvements had not been sustained and the provider was still in breach of the regulations.

This will be the third consecutive time the service has been rated requires improvement or inadequate.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to good governance and assessment and management of risk at this inspection. Please see the action we have told the provider to take at the end of this report. Full information about CQC’s regulatory response to more serious concerns is added to reports after any representations and appeals have been concluded.

Follow up

We plan to meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will request an improvement plan and revisit the service as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Hall Lane Resource Centre (Respite Care, Short Breaks Service) was last inspected by CQC on 31 August and 7 September 2017 and was rated inadequate overall. The overall inadequate rating resulted in the service being placed in special measures, as this is the Care Quality Commission’s standard process.

At the last inspection we found multiple breaches of regulations in relation to Regulation 12 - safe care and treatment; Regulation 13 - safeguarding service users form abuse and improper treatment; Regulation 9 – person-centred care; Regulation 16 - receiving and acting on complaints; Regulation 18 - staffing; Regulation 10 - dignity and respect and Regulation 17 - good governance.

At this inspection we found improvements had been made. We identified a continued breach of Regulation 17 HSCA RA Regulations 2014, good governance. There was a lack of oversight of some aspects of the service and issues we found had not been identified by the auditing processes in place. These needed to be more robust. We judged the service was compliant with all other regulations.

Hall Lane Resource Centre (Respite Care, Short Breaks Service), referred to throughout this report as Hall Lane, is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Hall Lane provides short breaks (respite care) and accommodation for up to ten people, younger and older adults, with a learning disability or autism. The service is based on the first floor and shares the building with a day service on the ground floor and office space for managers, also on the first floor. There are ten bedrooms, one with en-suite facilities, a main lounge and a quieter lounge, a communal kitchen and easily accessible bathrooms incorporating wet rooms. On the day of our inspection there were six people staying at the home, four of these being emergency placements. However, there were around 60 people who used the service in total.

Care services for people with a learning disability and autism should be developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using services can then live as ordinary a life as any citizen. Hall Lane was not a new service. Whilst this service was not full at the time of our inspection it can cater for up to ten people at any one time. It was accessed by people both local to the area and living further away due to the nature of the service. Those that were able to accessed the local community independently.

The service had a registered manager in place. They had been newly appointed to this role since the last inspection, and had previous management experience of the short breaks service. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

After our last inspection the service had placed a voluntary suspension on new admissions so that it could work on improving and ensuring people were kept safe. People accessing Hall Lane on a respite basis were already known to staff. We noted one emergency admission had taken place immediately prior to this inspection despite the voluntary suspension still being in place. The registered manager explained to us the reasons for this and we judged that because of the circumstances behind the admission and the measures put in place, the person was kept safe from harm whilst staying at Hall Lane.

The way the provider identified, documented and responded to incidents of potential abuse had improved and people were sufficiently protected from risk. Staff had been trained in safeguarding vulnerable adults and more training was scheduled

Since the last inspection, management had introduced a confirmation visit checklist. Contact was made prior to arranged stays to gather important information and to clarify any changes in need.

The management of medicines had improved but room temperatures in relation to where medicines were stored had not been recorded. On bringing this to the registered manager’s attention a thermometer was purchased for the locked store room.

We raised a potential infection control issue with the registered manager as this had been shared with us in a conversation with a relative. The registered manager took advice and guidance from environmental health and we were assured that the risk of people using the service being exposed to the spread of infection was minimal.

There were sufficient numbers of staff on duty to meet the needs of people who used the service. Staff were suitably trained and training sessions were planned for any due or overdue refresher training. Staff received regular supervisions and although staff did not yet receive annual appraisals they felt supported in their roles. A new staff appraisals process was being adopted.

Where people did not have the capacity to consent, procedures had been followed to make sure decisions made on their behalf were in their best interests.

Where people had capacity, we noted some involvement in the planning of their own care and consenting to care, however this was not consistent. The service was working within the principles of the Mental Capacity Act 2005 (MCA) and was following the requirements in the Deprivation of Liberty Safeguards (DoLS). However, the registered manager acknowledged that further improvement was necessary.

People's health was monitored, and any changes which required additional support or intervention were responded to. The service had an excellent relationship with a local GP’s surgery and they were able to register people staying at the service as temporary patients.

People’s privacy and dignity were respected by support staff. We heard a staff member knock on a person’s door before entering. The staff member was checking they were okay.

People were encouraged to maintain some life skills and become more independent. We only saw one daily living skills assessment on file, and the service acknowledged that more could be done in this respect.

People’s care plans prompted staff to consider any needs arising from people’s race, sexuality, religion and culture for example. The service was taking into account any protected characteristics when providing care and support. The service was aware of the recent changes in the law with regards to data protection and had changed working practices in order to maintain confidentiality and preserve people’s privacy.

Relatives were involved in helping form support plans. Other health professionals had visited the service to advise and guide staff, and to co-ordinate the changes in people’s care and support. A support plan we saw contained prevention strategies for the individual and staff to follow to prevent escalation of any situations and minimise the risks to the person. This care plan had also been updated following meetings with the individual and other professionals. The service could demonstrate they were working with people to help them achieve their goals.

There was no programme of activities in place based on what individuals wanted to do. However we saw additional staff were placed on duty so that people could be taken outdoors or to do things in the community. We saw, and people told us that outings included people being taken out for pub lunches, on the tram and to the park either in small groups or on their own.

We saw no evidence of materials around the home to help people with sensory impairments to make their own choices in their treatment and support.

The service had introduced a formal process to deal with any complaints raised with the service. There were new ways of working to try and reduce the number of complaints. People who used the service and family members were aware of how to make a complaint and told us they would have no problems in doing so.

The registered provider had some quality assurance systems in place, but there were no internal audits of the kitchen environment. Some issues we found had not been identified through the audit and quality assurance processes and therefore we identified a continued breach of Regulation 17 – Good Governance.

The service had engaged with the people who use the service, the public and staff. The service had held a coffee morning and had issued a short breaks newsletter introducing the new members of management. Family members and staff had been consulted about the quality of the service and feedback was positive, although the results of this feedback had not been analysed or shared. Family members said the management team were approachable. Staff were also better engaged with supervision, team meetings and an away day had taken place. Staff felt supported by the new management team and were comfortable raising any concerns.

Whilst there had been some improvements to how the provider and manager monitored the safety and quality of the service, there remained room for further improvement in the key area of well led. The limited audits and checks carried out had not identified all the issues we found, such as in relation to food, medicine temperatures, recording in care plans and staff bypassing the safety mechanisms

There was a registered manager in post at the time of our inspection but they had not been in work for approximately eight months prior to our inspection. They were not present at the inspection and the inspection was supported by an acting manager who supported the centre on a part time basis.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’

During this inspection, we found breaches of Regulations 9, 10,12,13,16, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We are currently considering our enforcement options in relation to these breaches.

We looked at three care plans. Two of the three care files we looked at failed to clearly identify people’s needs and risks. We found that some of the risks in relation to people’s care had not been risk assessed and some of the risk management information was contradictory and confusing for staff to follow. This placed people at risk of receiving inappropriate or unsafe care. By day two of the inspection, the acting manager had taken some steps to address this.

We saw that in two out of the three care files we looked at staff had information on the person’s likes and dislikes, personal hygiene preferences and daily routines. There was also some good information on people’s personal history and their ability to communicate. In one of the files we looked at, sufficient information in all these areas was missing. By day two of the inspection, action had been taken to address this.

We found that improvements with regards to how the service assessed the capacity of people to participate in and consent to the planning and review of their own care was required in order for it to comply in full with the Mental Capacity Act. We saw however that no major life decisions had been made about people’s care. For example, a deprivation of liberty safeguard or do not resuscitate decision. Care plans contained sufficient information about how people communicated their wishes for staff to determine if they consented to their day to day care.

We found that safeguarding incidents were not always recorded, investigated or reported appropriately. Incidents of a safeguarding nature had not always been identified and responded to and the provider lacked a robust system to protect people from the risk of abuse.

Medication was not always stored securely. Prescribed creams and other prescribed medication such as antibiotics were found on display in people’s bedrooms. This placed them at risk of unauthorised use. Some people’s medication administration charts were confusing and open to interpretation. This meant there was a risk that staff would not have the same understanding of how to administer the person’s medication in order to ensure it was administered safely. We found gaps in the administration of one person’s lunchtime medication. When we investigated this further, we found that the service had no protocols in place to ensure the person received this medication when they were away from the service.

There was mixed feedback from the people and relatives about whether the number of staff on duty was sufficient to meet people’s needs. Staff supervision records showed that staff had raised concerns about poor staffing levels and the impact this had on the ability of the service to provide safe and appropriate care. We found no evidence that these concerns had been acted upon by the management team. The service had a small team of permanent staff but relied on agency staff to plug gaps in staff rotas where one to one support for people was required. When we looked at the staffing system in place we found it to be overcomplicated and ineffective and there were times when due to this, the service was left understaffed. This placed vulnerable people at increased risk of unsafe and inappropriate care.

We saw that staff had received supervision in their job role but found this supervision was not always supportive as staff concerns had not always been responded to. There was evidence that the skills and abilities of staff were appraised but we found the appraisal process to be generic and not centred on the individual. Staff training was not up to date and some staff lacked sufficient training to enable the provider to be assured they could do their job role effectively.

We saw that there were a significant number of concerns raised by people’s relatives about people’s personal belongings not being returned when the person returned home. We found little evidence that these concerns had been addressed and little evidence that the provider had a system in place to ensure people’s personal belongings were secure. This did not indicate that people’s personal belongings were treated with respect.

People told us that the majority of staff treated them well. Most of the staff we observed supported people in a kind, caring and patient manner. We saw that most staff were person centred in their interactions with people and ensured people’s choice was promoted in the day to day delivery of care. Some of the agency staff we observed although kind and attentive when people required support sometimes failed to interact with the person they were supporting in any meaningful way.

People told us the food was good and that they got enough to eat and drink. During our visit, we saw that people’s meals were provided in a person centred way. For instance, at a time when the person wanted their meal, as opposed to set mealtimes and people had unlimited access to drinks as and when they required them.

Some of the people who stayed at the centre, attended a day centre, a separate service, located on the ground floor of the same building. The acting manager told us the day centre provided a range of activities. We found however that if people did not want to attend or were unable to attend the day centre, there were no alternative activities or outings organised by the provider for them to participate in during their stay. This did not indicate that people’s social and emotional needs were assessed, planned for and met by the provider.

This service was not well-led. The service lacked adequate local management and governance arrangements. The system in place were centralised to the Local Authority and did not enable local intelligence to be analysed and monitored by the service itself so that service specific improvements could be made. There were no local audits in place to assess, monitor and mitigate risks in relation to people’s care, accident and incidents, safeguarding, medication, staffing and staff support or people’s views and opinions on the service provided. This meant that the concerns we identified during our visit had not been identified or addressed.

At the end of our inspection, we discussed the concerns we identified during the inspection with the acting manager and other senior managers from the Local Authority. They accepted the concerns we had raised with regards to the service. We also raised concerns about their failure to consistently notify the Commission of notifiable incidents.