Hayes Court

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance arrangements at the service.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Leaders described a strong ethos of providing a welcoming, family‑run service where people were supported to live well together. Staff and leaders consistently spoke about Hayes Court being a “home from home”, and staff demonstrated long‑standing commitment to the service, with low turnover and many staff having worked there for several years. This stability supported continuity of care and positive relationships with people and relatives.

Staff told us they felt proud of the culture and teamwork within the home. People and relatives also reported positive experiences.

Leaders understood the context in which the provider delivered care and support. They embodied the culture and values of their workforce and organisation. Leaders were visible and approachable, and staff consistently described feeling supported by the management team. One care worker told us, “It’s a happy job… we are happy.”

However, leaders did not always demonstrate sufficient oversight of regulatory responsibilities or best practice guidance. For example, the manager was not aware that Deprivation of Liberty Safeguards notifications needed to be submitted to CQC and had not submitted notifications for a serious injury until prompted. They had not ensured they had stayed up to date with best practice guidance and ensured this was incorporated into service delivery, including in relation to the Accessible Information Standard and dementia friendly environments.

Staff felt they could speak up and that their voice would be heard. Staff told us they felt able to raise concerns informally and described an open‑door approach from managers. One staff member said there were “open discussions and suggestions are listened to.”

However, formal arrangements to support freedom to speak up were not fully embedded. The whistleblowing policy was outdated and did not reference a freedom to speak up guardian, limiting clarity for staff about how to escalate concerns safely outside the line management structure if needed.

The provider did not always focus on proactive continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research.

Leaders described learning from complaints and incidents, and there was evidence of complaint analysis and satisfaction surveys being reviewed, which had led to improvements in areas such as laundry services.

However, learning from key information was not consistent. Audits did not consistently identify risks, particularly in medicines management and environmental safety. Whilst leaders responded to the feedback provided as part of our assessment, they did not have effective systems in place to proactively identify and improve their practice.

Leaders had plans to improve systems, including further embedding electronic care records and introducing online training, but these improvements were not yet fully implemented at the time of the assessment.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider did not have effective arrangements to ensure consistent oversight of quality and safety. Governance systems were in place but were not effective in identifying or managing risks, including in relation to the management of medicines.

There were gaps in audit systems, with no infection prevention and control audits and limited care record audits. Policies were outdated, including safeguarding and whistleblowing, and there was no policy to support the Accessible Information Standard, despite people with sensory impairments and communication needs using the service. Leaders relied heavily on informal oversight and did not consistently use quality data to drive improvement, which placed people at risk of harm and reduced the sustainability of the service.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The provider worked constructively with partners and the local community to support people’s care. The service had established positive working relationships with healthcare professionals, including GPs, pharmacists, rapid response teams and hospice services. Staff described good access to advice and support from community professionals when needed.

The home also engaged with community groups and activities, such as schools visiting at Christmas and external entertainers.

The provider did not always focus on proactive continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research.

Leaders described learning from complaints and incidents, and there was evidence of complaint analysis and satisfaction surveys being reviewed, which had led to improvements in areas such as laundry services.

However, learning from key information was not consistent. Audits did not consistently identify risks, particularly in medicines management and environmental safety. Whilst leaders responded to the feedback provided as part of our assessment, they did not have effective systems in place to proactively identify and improve their practice.

Leaders had plans to improve systems, including further embedding electronic care records and introducing online training, but these improvements were not yet fully implemented at the time of the assessment.