The Hall

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

We found that people were not safe living at The Hall. People could display high levels of distress, and incidents escalated quickly due to staff presence. People were subject to restraint, which was unlawful and sometimes excessive. When people had been restrained staff failed to complete any observations on people or document any injuries on body maps. Staff did not have de-briefs following incidents, and similar incidents reoccurred due to lack of learning, and updating care plans and risk assessments. Staff did not understand their safeguarding duties, as incidents of abuse had not been reported to the local authority safeguarding team, or to the CQC. The principles of RCRSRC were not met; people were not kept safe from avoidable harm. The environment of the service was not supportive of people with a learning disability or autistic people. There were not always sufficient numbers of qualified and capable staff to keep people safe. Staff had not been recruited following robust recruitment processes. Medicines were not managed safely. We found three breaches of the legal regulations in relation to safe care and treatment, safeguarding, staffing, and fit and proper persons employed.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Relatives told us they were not informed when incidents occurred, that staff were not open and honest. One relative told us they had only been informed of one incident their loved one was involved in. A relative told us that staff lacked the knowledge and skills to de-escalate incidents, and failed to learn and make improvements following incidents. The relative told us that incidents had increased in duration and frequency since their loved one lived at the service.

Staff told us they understood their responsibilities in relation to incident reporting. However, we found that not all incidents had been documented. For example, during our assessment on 22 May 2024 we observed three incidents. When we returned on 30 May 2024 these incidents had not been documented. Staff were not always documenting incidents, and there was a lack of oversight of incidents to ensure this was done.

There were not robust systems in place to ensure that incidents were used as an opportunity to learn and improve. When incidents occurred, the documentation of the incident was poor, and was not always reflective of what happened. There was no oversight of accidents and incidents. Incident reports had not always been reviewed, and relevant follow up actions completed. For example, following incidents of distress, when staff used physical intervention on people, body maps were not completed for people, health checks and observations were not carried out on people, and there was no de-brief for staff. No changes had been made to people's care plans following incidents. There was a high volume of incidents at the service, however there was no overview or desire by the provider to review and reduce this. This placed people at risk of avoidable harm. There was a lack of oversight of incidents from the provider.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People had not been protected from abuse. One person was noted by a visiting professional to have bruising to their arms. The unexplained bruising had not been raised as a safeguarding and had not been reported to the person's social worker or the person's loved one. A different relative told us that unexplained bruising was identified on their loved one. This had not been documented or reported by staff. Another relative told us that their loved one had been accidently overdosed. This had not been documented and reported to the local authority safeguarding team. People had a poor experience living at the service. Some people living at the service had been subjected to numerous incidents of unlawful restraint. Some people had observed incidents of abuse which could have caused them distress. When people had been subject to abuse, the provider failed to take into account the impact the abuse would have on the person.

Although staff we spoke with told us they had a good understanding of safeguarding, and had received training, we found that staff did not always raise concerns when incidents of abuse occurred. Staff were involved, and observed an incident where a person became distressed and staff used physical intervention techniques, and force outside of the care planned intervention techniques, however staff did not raise this as a safeguarding concern. Staff failed to recognise this incident as abuse. Staff observed and were involved in numerous incidents of concern and abuse, however these were not raised either internally or externally by contacting the local authority safdeguarding team.

People were not kept safe from avoidable harm because staff did not understood how to protect them from abuse. During our assessment, we observed staff to be fearful of people, and people to be fearful of staff. For example, we reviewed an incident between a person and a staff, that escalated after the person sought interaction from the staff, and the staff flinched and moved away. The person then became distressed and the incident escalated. During incidents of significant concern we observed people to show little or no reaction to highly distressing situations. Following incidents where people had been subjected to force or physical intervention techniques which were not care planned, we observed people try to comfort one another.

There were not effective processes in place to ensure people were protected from the risk of abuse, or avoidable harm and some people had suffered abuse. When incidents of abuse occurred the provider did not consider the emotional impact on the person, and allowed staff to continue to work at the service. When people became distressed staff used physical intervention. The techniques and force used by staff were not always in line with any care planned physical intervention techniques. Other incidents of abuse had not been reported by the provider. Following the assessment, we raised 9 incidents of abuse with the local authority safeguarding team. These included; unlawful restraints, incidents of abuse between people, and incidents of abuse from staff. We also raised a safeguarding with the local authority safeguarding team regarding the use of CCTV within the service, as an excessive restriction on people.

Relatives told us that staff did not understand people well, and could not support them in times of distress. One relative told us it was important for their loved one to be busy and fulfilled, however, their loved one was not engaged by staff living at The Hall. During our assessment the person was not engaged in meaningful activities and spent most of their time wandering around the service.

Staff did not make every attempt to avoid restraining people. Staff used restraint before de-escalation techniques had been used. Staff we spoke with told us they did not observe excessive force, or inappropriate restraint used by other staff. However, we reviewed CCTV footage of incidents where this was the case. People were not restrained only where evidence demonstrated it was necessary, lawfully justified, used for the minimum period of time, had a justifiable aim, and was in the person’s best interest. There was not evidence to demonstrate that restraint was was used in a safe and proportionate way. We observed incidents were staff escalated the incident by crowding people and causing distress and avoidable harm.

People’s freedom was not restricted only where they were a risk to themselves or others, and was not used as a last resort and for the shortest time possible. We observed incidents of concern where staff told us they used an 'environmental barrier' to stop people moving freely within the service. During one incident a person was trying to leave their bedroom and staff were holding their door closed, preventing them from leaving their room. Staff told us this was to reduce the distress of the person, however the person remained distressed. During incidents of distress, staff 'crowded' people which often escalated the distress and the incident. Staff lacked the skill and competence to de-escalate situations.

People were not protected from the risk of harm. Care plans and risk assessments were not sufficiently detailed and were not followed during periods of distress. Care plans were not clear on what physical intervention techniques could be used if a person became distressed. After staff used restrictive practice, they did not take part in post incident reviews and did not consider what could be done to avoid the need for its use in similar circumstances. No one reviewed incidents of physical intervention to ensure they were lawful and used for the least amount of time, and there were no restraint reduction plans in place. There were high numbers of incidents of distress. There was a lack of action by the provider to review and reduce instances of distress. Other care plans and risk assessments were poor and had not been updated since 2021.

Environmental risks had not been assessed and mitigated. During our assessment we saw someone leave the service quickly and head towards the road. Staff intervened to stop the person accessing the road. There was no gate to stop people accessing the busy road. Another person living at the service would often sit on the drive, until they were ready to go into the service. The provider told us people were not at risk of running out into the road, however, they agreed to review the risk and install a gate to reduce risks to people.

We asked the manager and a consultant for information about the use of surveillance. We were not assured surveillance was used in the best interest of people or how people benefited from being monitored. The provider was unable to demonstrate how people had consented to the use of surveillance in their home. We asked for policies and information around the use of surveillance but none were provided which gave robust assurances people benefited from being under surveillance. We would expect the provider to have a Data Protection Impact Assessment in place to outline the reasons for surveillance use but this was not in place. We were not assured information was handled in a secure way.

The environment was not suitable for people living there, and was not in line with the principles of RCRSRC. The dinning room, living room and corridors were hot spots for incidents of distress. One person could become very distressed with loud noises, however their bedroom was connected to the living room where people gathered, and where incidents occurred. There was no risk assessment in place to inform staff how to manage this risk and reduce the distress to people. The manager confirmed there had been no consideration if this was the best suited room for the person.

People were not cared for in safe environments, designed to meet their needs. Staff told us that two people struggled with their mobility, and found a small step outside the kitchen a 'challenge'. The shower on the ground floor also contained a high step to access it. There was no risk assessment in place to inform staff how to mitigate any risks to the person. The provider had not considered how to make this more accessible for them, for example putting in a small ramp. There was a lack of oversight for the safety of the environment. Some safety checks were overdue, for example emergency lighting and fire alarms had not been safety checked since January 2023. The manager told us fire drills were overdue, they said, “I've only been here a month so couldn’t tell you when last one was. They should record it but I don’t know if the previous manager recorded it or not. I've not seen it recorded anywhere.” Personal emergency evacuation plans (PEEPS) lacked detail. One person PEEP stated they should be given ‘positive support’ and ‘verbal prompting’ but gave no detail of what this meant or what staff should say or do to support the person.

Relatives told us that staff lacked the skills, knowledge and competency to support their loved ones. One relative told us that staff 'goaded' people into becoming distressed. Relatives told us that agency staff lacked the skills and experience to support people. Relatives told us that their loved ones needed to be supported by consistent staff, who knew them well and were able to de-escalate any distress people showed. However, people were supported by agency staff, who didn't always know them well, which resulted in incidents occurring. Care plans including positive behaviour support guidance was out of date, and not followed by staff.

Staff told us there was no formal system to take a break, and often they would not take a break. Staff mostly worked 14 hour days without a formalised break. Staff told us that before our assessment, only smokers would get a break to smoke, and non smokers often would not have an opportunity to have a break.

On the first day of our assessment we observed there were not sufficient numbers of staff to meet people's needs and keep them safe. There was no formal system to ensure staff involved in incidents were given opportunities to de-brief following incidents. Staff did not have a formalised break, and would often not have a break. Staff were not given the time or opportunity to complete documentation, including incident reports. During incidents we observed that agency staff would retreat during periods of high anxiety as they were not trained to support people and de-escalate appropriately.

People were not supported by sufficient numbers of suitably qualified staff. Not all staff at The Hall had received training in physical intervention, safeguarding or supporting people with a learning disability. Since 1 July 2022, all registered health and social care providers have been required to provide training for their staff in learning disability and autism. There were not effective processes in place to ensure staff were recruited safely. Work histories had not always captured any gaps in employment explored. One staff had Disclosure and Barring Service (DBS) checks completed after starting their employment. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. A risk assessment had not been implemented to mitigate the risk of staff commencing work prior to the DBS check being completed. Out of the 3 recruitment files we viewed references received for 2 staff were not from the most recent employer from the care sector and there was no information recorded why. The provider had no assurances staff members would be suitable for their role. Often, agency staff would be required to support at The Hall. Agency worker profiles confirmed these staff had not been trained in physical intervention. During incidents of concern, agency staff did not always respond appropriately; for example one agency staff member jumped behind a piece of furniture during an incident of distress. The other staff member they should have supported was left to de-escalate the incident on their own. During other incidents of distress, agency staff are seeing pulling and grabbing people, using unapproved physical intervention techniques. People's care plans did not include summaries with essential information about people to ensure agency staff could quickly see how best to support them.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were not supported to receive their medicines safely. One relative told us their loved one had been overdosed on one of their prescribed medicines. They raised this with the manager who promised to investigate, however no safeguarding was raised, the error was not reported to CQC, and there was no evidence of an investigation of this incident. Another person told us that their loved one did not receive their medicines when they were prescribed, but rather when staff were ready to administer them. One person received a medicine routinely to help them to sleep, when it was prescribed on an 'as needed' basis. People prescribed paraffin-based skin products did not have individual fire risk assessments in place. Steps were not taken to ensure that excess residue wasn’t being held in clothes and bedding increasing the risk of fire. Some people at the service were smokers as which increased the risk to the people prescribed these creams. This was raised during the assessment and staff were unaware of the risk or the need for assessment. We asked that this be put in place to help ensure people’s safety going forward.

Although staff had been trained on the safe and effective use of medicines, competency checks were last completed on 18 May 2023 and were due to be renewed at the time of the assessment. These had not been scheduled to be completed at the time of the assessment. We were told by staff that there were never any supernumerary staff at the service which meant that staff were always allocated provide direct care. Staff therefore did not have any time to complete medicine checks, updating care plans relating to medicines, including ensuring that key guidance including 'as and when' guidance was in place to inform staff how to support people safely. We found instances where 'as and when' medicines were being used regularly without review.

There were processes in place to ensure that people received medicines safely, however these were not always followed. For example, staff were not following the process to accurately transcribe information onto the medicines administration records (MAR). This meant that there was risk that people may not receive their medicines as prescribed. Care plans and risk assessments often lacked person-centred detail for staff to know how to meet their needs. Access to medicines was not secure at the time of the assessment. We asked to review MAR for April 2024, and staff were unable to produce these. There were no records relating to medicine administration errors, although relatives told us there had been errors. There was a lack of oversight and auditing of medicines and medicines administration. Medicine audits had not been completed since the previous registered manager left the service in November 2023.