Harcourt Gardens Care 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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first assessment for this newly registered service. This key question has been rated 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 effective governance, as systems and processes were not always effective in ensuring improvements were implemented and sustained, risks were mitigated, and records were complete and accurate.

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 ensure that a clear and consistent culture of high-quality, person-centred care was fully embedded across the home. While staff spoke positively about teamwork and day-to-day support, this was not consistently aligned with the delivery of care in practice. Evidence from the inspection showed discrepancies between care planning and actual care delivery, including people’s preferences not always being followed, such as night-time routines not reflecting individual choices.

Although the provider had identified areas for improvement through governance systems and action plans, these were not consistently translated into practice, demonstrating that the service’s stated values and expectations were not fully embedded. Variability in people’s experiences, including reports of limited engagement and inconsistent involvement, further indicated that the culture of person-centred care was not consistently experienced by all people using the service.

This demonstrated that while elements of a positive culture were present, leadership had not ensured a shared understanding and consistent application of person-centred values across the home, limiting the overall effectiveness of the home’s culture.

Leaders were not consistently effective in ensuring the delivery of high-quality, person-centred care across the service. The service had an interim manager who had applied to register with the CQC. While the interim manager was described as approachable and responsive, and positive relationships were evident within the immediate team, this was not consistently reflected in outcomes for people. Evidence from the inspection demonstrated ongoing inconsistencies between care planning and delivery, including people’s preferences not always being followed and gaps in key areas such as consent, MCA application and end of life planning.

Leaders had systems in place to identify areas for improvement, and concerns relating to MCA, DoLS and care planning had been recognised within governance processes. However, these had not been effectively progressed or embedded into practice, as the same issues remained evident at the time of inspection. This demonstrated that leadership had not consistently ensured accountability, oversight and follow-through of actions, limiting their effectiveness in driving improvement.

While leaders responded appropriately to issues raised during the inspection, the persistence of known concerns and variability in people’s experiences showed that leadership was not consistently effective in delivering sustained, high-quality and person-centred care across the service.

The provider promoted a culture where staff felt able to raise concerns and speak openly about issues affecting people’s care. Staff told us there was “no fear” in raising concerns and described clear processes for escalating issues to senior staff and management. They demonstrated an understanding of safeguarding and whistleblowing procedures and were confident that any concerns would be taken seriously and acted upon.

Feedback from staff indicated there was an open and supportive environment, where communication within teams enabled concerns to be shared and discussed. Systems were in place to record and respond to issues, including incident reporting and safeguarding processes, supporting transparency within the service.

This approach ensured that concerns were identified and reported appropriately, contributing to maintaining people’s safety and wellbeing.

The provider promoted equality, diversity and inclusion within the workforce and in the delivery of care. Staff received training in equality and diversity, and policies were in place to support inclusive practice. Staff demonstrated an understanding of treating people fairly and respecting individual differences, including cultural, religious and personal preferences.

People’s care plans reflected their individual needs and backgrounds, supporting staff to deliver care in a respectful and inclusive way. A relative described the home as providing an environment that supported “equality of access for everyone,” indicating that people felt treated fairly. Staff worked to ensure people’s diverse needs were recognised and supported in day-to-day care.

These approaches supported an inclusive culture within the home, where people and staff were treated with dignity and respect.

The provider did not always have effective systems in place to assess, monitor and improve the quality and safety of the home. While audits, reviews and action plans were established and had identified key areas of concern, including Mental Capacity Act (MCA) compliance, Deprivation of Liberty Safeguards (DoLS) and end of life (EOL) care planning, these were not effective in ensuring improvements were implemented and sustained in practice.

At the time of inspection, care records continued to demonstrate gaps in these areas. This included incomplete or unclear best interest decision-making, consent recorded on behalf of people who had capacity and limited personalised end of life planning. In addition, inconsistencies between care planning and delivery, such as people’s preferences regarding night-time routines not being followed, showed that systems were not consistently ensuring care was delivered in line with assessed needs and agreed plans.

Although these concerns had been identified, improvements had not been embedded. The continued presence of these issues across multiple records demonstrated that governance systems were not effective in driving timely action, maintaining oversight or ensuring compliance with legal requirements.

This meant the provider could not demonstrate that risks were consistently identified, mitigated and reviewed.

The provider did not always ensure that partnership working consistently supported effective, person-centred care and decision-making. While visiting professionals gave positive feedback about communication, describing it as timely and responsive, this was not consistently reflected in how decisions were recorded and coordinated in practice.

Records relating to Mental Capacity Act (MCA) processes and best interest decision-making did not consistently evidence involvement of appropriate stakeholders, including professionals, families or representatives. This meant there was limited assurance that decisions were always made collaboratively, or that all relevant information and perspectives were considered when planning care.

In addition, inconsistencies between care planning and delivery, including where people’s preferences were not always followed, demonstrated that multi-disciplinary input was not always effectively translated into practice. This reduced confidence that partnership working was consistently achieving positive, person-centred outcomes for people.

The provider had identified these issues and had taken steps to improve partnership working and documentation; however, these improvements were not yet embedded, as the concerns remained evident at the time of inspection.

The provider did not always ensure that systems for learning, improvement and innovation were effective in delivering sustained changes to care quality. While there was evidence of audit activity, action plans and ongoing service development, these processes did not consistently result in improvements being embedded into practice.

Key areas of concern, including Mental Capacity Act (MCA) compliance, Deprivation of Liberty Safeguards (DoLS) and end of life (EOL) care planning, had been identified through governance systems. However, these issues remained evident at the time of inspection, with continued gaps in care records and inconsistencies in how care was delivered. This demonstrated that learning from audits, incidents and reviews was not consistently translated into measurable and sustained improvements.

Although leaders showed a willingness to improve and responded to feedback, the lack of progress in addressing known risks indicated that systems for learning and improvement were not consistently effective in driving change or improving outcomes for people. As a result, innovation and improvement activity did not always lead to meaningful or sustained enhancements in the quality of care.