CQC report explained · a residential care home
What the CQC found at Hall Lane Resource Centre (Respite Care, Short Breaks Service)
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Are people protected from harm? Staffing, medicines, infection control, safeguarding.
- Effective?
- Requires improvement
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Requires improvement
- Inspectors found improved quality checks, care record reviews, environmental audits and staff training records. The previous Requires Improvement rating was not changed because the whole well-led question was not assessed.
What inspectors found, February 2024
Inspected but not rated; inspectors found improvements after a previous Requires Improvement rating, but the full service has not been reassessed.
This was a targeted inspection on 23 and 26 January 2024. It checked whether the home had met a warning notice about its systems for monitoring and improving quality.
Inspectors found better oversight. Care records were checked and updated, audits identified areas for improvement, staff training records were accurate, and accidents and incidents were reviewed.
The home was no longer in breach of Regulation 17. However, this inspection did not cover the whole service. The overall rating remains Requires Improvement from the previous inspection, and the well-led rating was not changed.
Improved quality checks
The provider had strengthened its systems for checking the quality and safety of the service. Audits were said to reflect current activity.
“Improvements had been made to the quality assurance arrangements across the service.” from the report
Care records updated
Care records were reviewed before people received support and were updated to reflect their current needs.
“Care records were reviewed before a person received care and support and actions were taken to ensure care records were reflective of the person's current needs.” from the report
Staff preparation
Staff training records were accurate. Agency workers received an induction and the provider checked their training and experience.
“Agency workers received an induction when they commenced working at the service.” from the report
Learning from incidents
Accidents and incidents were recorded and reviewed to help reduce the chance of them happening again.
“Accidents and incidents were recorded and reviewed to reduce further occurrences.” from the report
Full rating not reassessed
needs fixingThis inspection only followed up a warning notice. It did not assess the whole well-led question or the other four questions, so the previous overall Requires Improvement rating remains.
“We have not changed the rating as we have not looked at all of the well-led key question at this inspection.” from the report
- 01What specific changes have been made to the quality checks since the previous inspection?
- 02How do you check that each person's care records are updated before a respite stay?
- 03How are agency workers' training, experience and induction checked before they support people?
- 04What improvements have been made to the internal and external parts of the property?
- 05When will the next comprehensive inspection assess the full service?
This was a targeted inspection of Regulation 17 and did not assess the whole well-led question or the other key questions; the previous overall Requires Improvement rating therefore remains. This explanation was written from the published report of 10 February 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, September 2022
Rated Requires Improvement; inspectors found kind support but serious gaps in risk checks, staff training, records and oversight.
This was a focused inspection on 5 and 11 July 2022. Inspectors reviewed care plans, risk assessments, staff files and audits. They also spoke with people, relatives, staff and health and social care professionals.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were also rated Requires Improvement. Inspectors found people were supported with choice and independence, and relatives spoke positively about staff. However, risks and care needs were not always recorded properly. Medicines were not stored in line with current guidance.
There were gaps in agency staff checks, staff training records and care planning. Audits did not always lead to improvements. The home remained in breach of Regulations 12 and 17 and was also in breach of Regulation 18. This was the fourth consecutive inspection where breaches were found.
Positive feedback
People's relatives spoke positively about the support they received. They said they would contact the registered manager if they had concerns.
“People and their relatives gave us positive feedback about the service.” from the report
Choice and independence
Staff supported people to make choices and encouraged independence. People were supported to access the community independently where possible.
“Staff supported people to have choice and control. People's independence was supported by staff.” from the report
Support with food and drink
Inspectors observed people being supported to eat and drink. Staff also knew about people's cultural food needs.
“Staff supported people to eat and drink. We observed people being supported to eat and drink.” from the report
Infection control
Inspectors were assured that the home used PPE safely, supported safe admissions and had an up-to-date infection prevention and control policy.
“We were assured that the provider was using PPE effectively and safely.” from the report
Risk information was missing
seriousRisk assessments were not always available, and some care plans did not explain people's complex care needs clearly enough. This was a continued breach of Regulation 12.
“Risks were not consistently assessed. This was a continued breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008” from the report
Staff checks and training
seriousThe home did not have effective checks to assess the suitability of agency staff. Some staff training was out of date, and training records were inaccurate.
“Agency staff were not supported with a formal induction. The provider regularly used agency staff.” from the report
Medicines storage
needs fixingMedicines were administered safely, but the storage room was also used for care plans. This meant access was not restricted to staff assessed as competent to administer medicines.
“Medicines were administered safely however they were not stored in line with current best practice guidance.” from the report
Audits did not lead to change
seriousAudits identified actions, but care plans had not always been updated. Other audits did not accurately reflect how the service was operating.
“Audits had not driven improvements. We found care plan audits had been completed and necessary actions identified.” from the report
Incomplete records
seriousRecords about incidents, recruitment, staff competence, handovers and care plans were not always complete or easy to access. The home remained in breach of Regulation 17.
“The provider was not operating effective systems to assess, monitor and improve the quality and safety of the service.” from the report
- 01Which risk assessments and care plans have now been updated, especially for people with complex care needs?
- 02How do you check the suitability, skills and induction of agency staff before they support someone?
- 03How are staff training records checked, including training for feeding tubes, medicines, safeguarding and DoLS?
- 04How are medicines now stored, and how are storage temperatures recorded?
- 05What actions from the audit plan have been completed, and how will you show that they have improved care?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected during this visit and the overall rating also used ratings from the last inspection. This explanation was written from the published report of 22 September 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Hall Lane Resource Centre (Respite Care, Short Breaks Service)
4 rated inspections over 5 years: the service has improved, from Inadequate to Requires improvement.
- February 2024Inspected but not ratedcurrent ratingWell-led: Inspected but not rated
Read what inspectors found at Hall Lane Resource Centre (Respite Care, Short Breaks Service) →
- September 2022Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Hall Lane Resource Centre (Respite Care, Short Breaks Service) →
- October 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- August 2018Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2017InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- July 2015
Registered with the Care Quality Commission on 27 July 2015.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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