Hadleigh 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 requires improvement. At this assessment, the rating has remained requires improvement. This meant the management and leadership were inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of the legal regulation relating to governance.

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 did not have a clear shared vision, strategy and culture based on transparency.

The provider’s systems and processes failed to identify some important events that must be notified to the Care Quality Commission through a statutory notification, including allegations of abuse. We discussed this with the Registered Manager, who told us they would submit these in retrospect.

Whilst we did not identify anyone who had come to harm, this contributed to the continued breach of regulation in relation to governance.

Equality, diversity and human rights were incorporated into staff training. Staff discussed their relevance and application to people's care during supervision and staff meetings.

The Registered Manager was responsive to our feedback and wanted to make changes to improve the quality of care. On day 2 of our visit, the Registered Manager told us about professionals they had contacted to support the improvements discussed. This included the local authority quality assurance team and an external trainer.

The Registered Manager frequently spent time with people and staff at Hadleigh Court and knew them well. A staff member told us, “I think the (Registered managers name) and (Deputy manager’s name), are doing a good job and they lead really well”, and “All the staff are lovely and caring and everyone had got all the love for the residents, it is a good team and (Registered Managers name) is amazing. I was here before (Registered Manager’s name) was a team leader, I have always thought it is amazing that she is now the manager and succeeding in turning things around, and I think it is very well run”.

Relatives told us they knew who the Registered Manager was. Comments included, “Everyone is really nice, but I have a good relationship with (Registered manager’s name) and (Deputy manager’s name). They have said to me, we are here for you too, you know”.

The Registered Manager fostered a positive culture where people felt they could speak up and their voice would be heard. Relatives told us they did not feel feedback had been actively sourced from them. However, they found the Registered Manager and staff approachable. Comments included, “I can always talk to (Registered Manager’s name) if I am worried about anything”, and “If I had a complaint, I would go to (Registered Manager’s name) because she is helpful and will always give me her undivided attention”.

Contact numbers for speaking up to external organisations were readily available for staff. Most staff told us they had regular supervisions and had the opportunity to speak up.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for staff. The Registered Manager told us, “We employ people if they are good for the role, doesn’t matter what sex, religion, or sexuality, we don’t discriminate”.

A staff member told us, “Staff work really well together, and they all get on and communicate well, and definitely everyone is treated the same regardless of the background they are coming from”.

The provider did not always have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes. Audits were not always completed regularly; the provider’s oversight process was either not embedded or robust enough. The provider did not always assess, monitor and mitigate the risks relating to the health, safety and welfare of the people living at the service. For example, oral health audits were documented as required monthly, but the record showed they had not been completed for 3 months. Some care plans lacked guidance on how to care for a person, putting people at risk of harm. Although care plans and risk assessments were regularly reviewed, the provider did not have a system in place to ensure these reviews were effective. For example, ensuring they had up-to-date information about a person’s current needs and preferences. The service did not have a process in place to identify improvements needed in relation to diabetes, skin damage and ensuring the service was acting in accordance with the requirements of the Mental Capacity Act 2005. The service governance processes failed to identify the shortfalls identified in our assessment.

Whilst we did not identify anyone who had come to harm, this contributed to the continued breach of regulation in relation to safe care and treatment, and new breaches identified in relation to consent to care and treatment, staffing, and governance.

The service did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Whilst in practice the service worked in collaboration with other stakeholders, they did not always make robust records around this. This meant it was difficult to audit and fully understand the care and treatment people had received, or when professionals made recommendations. This placed people at risk. For example, people were deprived of their liberty, and the service did not have the most up-to-date records and relevant records of professional input. We signed-posted the Registered Manager to follow this up with the local DoLS team.

The provider did not always focus on continuous learning, innovation, and improvement across the organisation. The provider did not always monitor progress and take appropriate action without delay where progress was not achieved. At our last inspection we identified a breach in relation to safe care and treatment, at this assessment there continued to be a breach of of regulation in relation to safe care and treatment. The service was not able to provide us with provider-level audits. This contributed to the breach of regulation relating to governance.