Hebburn Court Nursing Home

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 inadequate. 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 continued to be in breach of legal regulation in relation to governance 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 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 culture of the home was becoming more person-centred. Staff commented that the culture and atmosphere was improving over time. A staff member told us, “It is getting better. Staff morale is still a bit low but it is moving in the right direction.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leadership and management was now more settled. A new manager had been employed since the last inspection but their application to register with the CQC had not been completed. This was done shortly after we visited the home and the manager was now registered with the CQC. Staff gave positive feedback about the manager. A staff member told us, “[Manager] is absolutely fantastic. She will do anything for you. She is very understanding, her door is always open.” There was still input from the external consultant, who had been brought in to oversee improvements to the home.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

There had been no concerns raised since the last inspection. Relatives confirmed they were involved in their family member’s care and could approach staff or the manager, if needed. A relative said, “The staff and management keep me up to date on my [family member’s] progress and always discuss any issues or queries I have. It is clean and I see staff cleaning multiple times per day.”

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.

The provider had policies and procedures relating to equality diversity and inclusion.

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, or share this securely with others when appropriate.

The provider had a more structured system of quality assurance. Audits were being completed more effectively than at the last inspection and identifying some issues. However, there were still inaccuracies in care records which had not been identified through audits. Although the systems had improved, more time was needed to ensure they were effective.

The provider 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.

The provider was still working with a range of external partners to improve the service. They were making progress on completing the action plan developed at the time of the last inspection. However, further time was needed to embed new procedures.

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 had improved the systems to monitor and mitigate risks associated with people’s safety, and to learn lessons to prevent situations from happening again. Falls, incidents and accidents were now being analysed. However, these lacked analysis and needed more time to ensure they were effective.