The Hall

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The provider failed to identify the significant and widespread issues highlighted during this assessment. There was a lack of robust oversight and governance, which led to people being at risk of avoidable harm. The provider had failed to audit and review the quality of the service, and identify areas needing improvements. There was a lack of learning and oversight in relation to incident management. Regulatory requirements had not been met, including the need to notify the CQC of incidents and share information of incidents with people and their loved ones (where appropriate). There was a poor culture in the service, which left people at risk of harm. Focus was not on the people living at the service. Staff lacked the training and competence to understand their responsibilities in relation to raising concerns within and outside of their organisation. There was a lack of effective leadership at the service. We found three breaches of the legal regulations in relation to good governance, duty of candour and notification of other incidents.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us there was a positive culture at the service, however we identified this was not the case. Staff did not always act appropriately, for example, staff smoked with people, and staff unlawfully restrained people, and at times used excess force.

Staff and leaders did not demonstrate a positive, compassionate, listening culture that promotes trust and understanding between them and people using the service and is focused on learning and improvement. The provider failed to identify and address the closed culture within the service. A closed culture means a poor culture that can lead to harm, which can include human rights breaches such as abuse. The provider had not addressed the closed culture and this led to people not being treated with dignity and respect. People's human rights were not upheld because they were unlawfully restrained. Documentation relating to people was sometimes outdated, not respectful and not person-centred. The provider had failed to identify this and take action to make improvements to the service.

Although staff told us that the leadership of the service was good, we found this was not always the case. Roles and accountabilities were not clear; staff did not comply with their responsibilities in relation to safeguarding people, and raising concerns within their organisation or externally. Staff did not always document incidents. Staff and leaders did not share concerns with relevant stakeholders.

Leaders did not have the experience, capacity, capability or integrity to ensure that risks are well managed. There was no registered manager in post. The registered manager left the service in November 2023. There was a new manager, who had been in post 5 weeks. There was a lack of oversight and support for the new manager. There was no deputy manager in place. Leaders lacked key knowledge around important guidance, such as RCRSRC and safety alerts, for example in relation to having risk assessments, and knowing the risks of paraffin based creams. Leaders were not alert to examples of poor culture that may affect the quality of people’s care and have a detrimental impact on staff. When incidents of poor care were identified, these were not addressed quickly. For example, when it was identified that staff had used physical restraint techniques outside the agreed care planned techniques the provider did not suspend the staff, and they continued to work within the same service.

Staff and leaders did not always act with openness, honesty and transparency. Although staff told us they raised concerns to the provider relating to previous management, they failed to raise serious concerns about the conduct of staff.

Processes to ensure staff understood their responsibilities to share concerns were not always effective. Staff had not shared concerns outside of the service, for example raised safeguarding concerns with the local authority. The provider failed to identify the closed culture within the service. The provider missed opportunities to learn from incidents, share learning with staff and implement improvements including ensuring staff understood their responsibility to share any safeguarding concerns.

Staff told us that before our inspection they did not always have time or opportunity to take their break. Staff told us that staff who smoked were able to take breaks to smoke or vape but that non-smokers didn't get the same opportunity. The provider failed to identify that staff had no opportunity to take breaks, and address this.

Leaders did not always take action to continually review and improve the culture of the service in the context of equality, diversity and inclusion. There were not effective processes in place to ensure the well-being of staff. For example, following incidents of distress, staff did not receive a de-brief. Processes were not in place to ensure staff received their break on every shift worked. Processes were not in place to enable staff to swap in and out when someone was particularly distressed, or following an incident. This placed people at risk of harm.

There was a lack of provider oversight of the service. The provider failed to identify the serious and significant concerns highlighted within this assessment. During a safeguarding meeting, the providers representative said, "We knew things were going wrong ... but we didn't know how bad things were." Staff told us they understood their roles, however we identified that staff did not always follow processes. For example, staff did not always complete incident forms, staff did not always raise safeguarding concerns internally or externally.

There were ineffective processes in place to monitor and improve the service. Checks and audits had not been robustly carried out. For example, a medication audit had last been completed in December 2023. Other audits, such as care plan audits, had not been carried out. Some care plans had not been updated since 2021. The provider failed to identify that incident reports were not reflective of the events that occurred in the service, and that incident reports were not always being completed. Services that provide health and social care to people are required to inform the CQC, of important events that happen in the service. This enables us to check that appropriate action had been taken. The provider had failed to inform the CQC when safeguarding incidents occurred. For example, when a person had unexplained bruising this was not reported to CQC. When people were unlawfully restrained, and staff used techniques outside of the agreed care planned this was not reported to CQC. When incidents occurred between people, for example when one person hit another person this was not reported to CQC. Following the assessment, we raised 9 safeguardings with the local authority safeguarding team. We shared 2 safeguarding concerns with Kent Police. We shared our concerns with the information commissioners office regarding the provider failing to follow guidance around the use of CCTV, and the policies surrounding the need of CCTV.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us when incidents occurred, they documented them and left them for the manager to review. However, we found this was not always the case. During our assessment on 22 May 2024, we observed 3 incidents. On the second day of our assessment on the 30 May 2024 these incidents had not been documented. We found that the manager had not reviewed all incidents, and appropriate action to review, and investigate incidents had not occurred. There was no learning or desire to reduce incidents of concern.

There were ineffective processes to ensure that lessons were learnt and improvements made. There was no oversight of accidents and incidents. The manager told us that incidents were documented and then filed in people's care plans. However, we found some incidents were documented on the providers online system, and others were not. There was not a clear system of how and where to report and document incidents. Incidents had not always been reviewed by the manager or provider to ensure appropriate action had been taken. The provider had not identified that staff were using physical intervention, and had not implemented a physical intervention reduction plan. We found that incident reports were not always documented factually. The provider failed to review incidents to ensure they were reflective of incident reports. There was no oversight of incidents. Behavioral charts should have been completed monthly to review, and learn from incidents, however this had not been done. When incidents occurred, care plans had not been reviewed and updated to inform staff of any new concerns, potential triggers or de-escalation techniques. There was no review of incidents to look for patterns and trends, including for example when incidents occurred or which staff were involved. When staff were involved in incidents of concern, for example using excessive force, there were no efforts made by the provider to review and take appropriate action, including any disciplinary action. People were placed at risk of avoidable harm.