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

Updated 10 February 2024

The inspection

This was a targeted inspection to check whether the provider had met the requirements of the Warning Notice in relation to Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Inspection team

The inspection team consisted of 1 inspector.

Service and service type

Hall Lane Resource Centre (Respite Care, Short Breaks Services) is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Hall Lane Resource Centre (Respite Care, Short Breaks Services) is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

We gave the service 24 hours’ notice of the inspection. This was because the service is small, and we wanted to be sure the registered manager was available to speak with us.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with the registered manager, the operations manager, and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We were introduced to the coordinators and 2 staff members. We also observed 2 people currently in receipt of respite and short breaks.

We reviewed staff training and competency records and agency staff records and inductions. We checked 3 care records and audits to ensure they reflected people’s current needs. We reviewed the previous 6 months of governance audits for the internal and external property, accidents and incidents and medicines management.

Updated 10 February 2024

About the service

Hall Lane Resource Centre (Respite Care, Short Breaks Service) is a residential care home providing accommodation with personal care to up to 10 people. The service provides support to people on a short- term basis providing respite support including people with learning disabilities and autism. At the time of our inspection there were three people using the service.

The layout of the service is based on the first floor of a resource centre. The service is situated above a day centre. There are offices relating to this service and the provider’s other services located on the same floor. The layout of the service does not meet the current best practice guidance for supporting people with learning disabilities.

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

At the time of the inspection the service had identified areas of improvement and an action plan was in place. Areas of improvement identified included training and care planning. We found audits carried out at the service were not always reflective of the service being provided. Audits were not always followed up to show that necessary improvements had been made. At this inspection, we found that further improvement was required in relation to care planning. Medicines were not stored in line with current guidance. We have recommended the provider reviews guidance in this area. Staff wore personal protective equipment (PPE) appropriately and the service conducted regular audits in relation to COVID-19.

Relatives of people using the service gave positive feedback about the support they received from staff. We observed people receiving support from staff in line with their assessed needs. The provider did not have effective systems in place to assess the suitability of agency staff at the service. The training matrix showed gaps in staff’s training around safeguarding and deprivation of liberty. Records relating to staff training had not been accurately maintained.

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.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Based on our review of safe, effective and well-led, the service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.

Right support: Staff supported people to have choice and control. People’s independence was supported by staff. People living at the service were mainly supported on a short-term basis and lived in the local area. There were also people living at the service as an emergency placement for several months. People were supported to access the community independently, where possible. The service was used by people, living in the local area, for respite support.

Right care: Care records did not consistently contain sufficient information to support people. Staff at the service appeared to know people well and the management acknowledged that this information was not consistently recorded in care plans. People’s cultural beliefs were respected.

Right culture: The service acknowledged previous concerns and had developed an action plan to drive improvement. The registered manager had arranged a meeting with relatives and people using the service. People and their relatives spoke positively about the new management team.

During the inspection, the registered manager discussed the services plans for refurbishment to create a more homely and welcoming environment at 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 requires improvement (published 1 October 2019). At this inspection we found the provider remained in breach of regulations. This service has been rated requires improvement for the last four consecutive inspections.

At our last inspection we recommended that the provider implemented person-centred care planning. At this inspection we found care plans continued to lack specific details in some areas. The necessary improvement had been highlighted on the service’s action plan and staff were in the process of updating care plans to a more person-centred format.

Why we inspected

The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to initial inquiries to determine whether to commence a criminal investigation. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of enteral feeding and medication administration. This inspection examined those risks. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

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 remained requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this report.

You can see what action we have asked the provider to take at the end of this report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Hall Lane Resource Centre (Respite Care, Short Breaks Service) on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment, staffing and good governance 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 the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will 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 work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.