Harvey Lane

Updated 3 January 2024

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection visits were carried out by 2 inspectors.

Service and service type

Harvey Lane 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. Harvey Lane 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 not a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed all the information we had received about the service since the last inspection. We sought feedback from the local authority and health professionals who had visited 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 3 people who used the service and 2 relatives. We observed the care and support provided, as well as the physical environment. We spoke with 11 members of staff. This included the peripatetic manager, the deputy manager, the area director, 3 team leaders and the provider’s positive behavioural support lead. We reviewed a range of records. These included various care and support records for 5 people using the service. We looked at 2 staff files in relation to recruitment. A variety of records relating to the management of the service, including audits and incidents were reviewed.

Due to the seriousness of the concerns the inspectors and an operations manager also met with the compliance and quality director, the area director and the 2 managing directors one of whom was also the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. This was so we could ensure the provider understood the seriousness of the risks identified and seek assurances they were being addressed. We asked the provider to submit an improvement plan so we could review and check actions were being taken to make urgent improvements. We returned on a second day to check this.

We liaised with local authority and health professionals during our inspection due to the serious concerns who also carried out visits to check on the safety and welfare of the people living in the service.

Updated 3 January 2024

About the service

Harvey Lane is a residential home providing personal care to up to 8 people with a learning disability and/or autistic people. At the time of our inspection there were 6 people using the service. Accommodation was provided on the ground floor, with each bedroom having ensuites. There was a communal lounge, dining room, and sensory area.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support:

People did not have full control and choice over their lives. This was because staff practice did not empower people to be independent and systems to ensure they were listened to were not effective. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. We were not assured people were receiving effective 1-1 or 2-1 staff support as required. People were not supported with their health care needs because staff did not always seek external professional support in a timely manner and when required. People were not supported to manage risks to themselves and from the environment. This placed people at risk of harm.

Right Care:

Incidents were not used to support staff learning and ensure people were receiving the right support. We were not assured staff understood how to support distressed behaviour and their support had contributed to incidents of distressed behaviour occurring. This placed people at risk of harm. People’s living environments did not promote their dignity. The support provided was not fully person-centred because staff were not following people’s care plans and these were not updated when needs changed.

Right Culture:

Governance systems in the service were ineffective as they had failed to ensure regulatory requirements were met. Leadership was weak and staff had not received effective support. Improvements to the culture were needed in order to ensure people received effective person-centred support.

We raised our concerns with the provider during the inspection. The provider took immediate action to address the risks within the service. We identified some initial early improvements between our first and second visit.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 8 August 2017).

Why we inspected

The inspection was prompted in part due to concerns received about the management of risk to people’s safety, medicines, and staffing. A decision was made for us to inspect and examine those risks.

Following our first visit to the service we raised our concerns with the provider. We returned on a second day to check they had taken action to address the immediate risks. We found the provider had taken effective action to make initial improvements.

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

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, staffing, deprivation of liberty authorisations, person-centred care, and good governance.

Please see the action we have told the provider to take at the end of this report.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.