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 was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to governance. At this assessment and the provider remained in breach of this regulation.

This service scored 61 (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 which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The service had been through significant change since our last inspection including changes in management and senior staff. The provider had a clear plan for improvement and the culture they wanted to create, and were working to understand the needs of people and develop a strategy for the service. One staff member told us, “Things are going in the right direction. We have a good team here.” A second staff member said, “I can see a brighter future. We had a discussion recently where we manifested what Hadleigh should look like. [The provider] is on hand and has an open-door policy, we want to improve as a team and we will all get there together.” People’s relatives also noted improvements in the culture of the service. One person’s relative told us, “It seems more relaxed, there’s a better atmosphere.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Following our last assessment, the provider appointed a new nominated individual who took responsibility for the day to day running of the service. The previous registered manager left the service, and a new manager was appointed. Shortly after the on-site assessment, the provider informed us the new manager had also left the service. There had also been changes within the senior staff team. Two consultants had been engaged to support improvement. The changes in leadership over a short period of time impacted the quality of oversight and culture of the service.

The provider took an active role in the day to day running of the service and appointed a new manager shortly after the on-site assessment. They told us the changes in management had a positive impact and were confident the leadership of the service would stabilise. One person’s relative told us, “I feel listened to in the last couple of months. Things run properly from what I can see, and I have no concerns.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt confident raising concerns. The nominated individual was on site daily working with the staff team, and seeking continuous feedback.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Hadleigh Court had a diverse workforce and all the staff we spoke with told us they felt valued, respected and well supported.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

The provider had introduced a new governance system and work had started to embed it. However, systems had not identified the concerns found during this assessment. For example, a mental capacity audit failed to identify inconsistencies across assessments or poorly completed documentation relating to mental capacity tests, which could have led to incorrect conclusions about people’s capacity. Care plan audits had been completed; however they failed to identify out of date information, which put people at risk of receiving unsafe or incorrect treatment. Governance systems failed to identify gaps in recruitment processes, poorly completed repositioning charts or fluid records.

This contributed to the continued breach of regulation in relation to governance.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked with the local authority to drive improvement. They shared information openly.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider recognised this as an area of improvement and were taking action to address it. For example, they had recently completed a Kings Fund environmental assessment to identify how they could best improve the service for people living with dementia.