Archived: Hevercourt

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

Systems to ensure that people were protected from the risk of harm were poor and ineffective. Staff missed the opportunity to identify and mitigate risks to people, and as a result people were placed at increased risk of harm. Systems to record incidents of abuse were not effective. Accidents and incidents oversight missed the opportunity to review incidents of distress or sexualised behaviour as well as choking risks. We found there were not sufficient numbers of staff to support people. Medicines were not always managed safely; the oversight of this was also not effective. Parts of the service remained worn and difficult to keep clean. The service was in breach of legal regulation in relation to safe care and treatment, safeguarding, staffing and fit and proper persons employed.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At our last assessment, we identified that oversight of accidents and incidents was not robust. At this assessment we continued to find concerns. The deputy manager told us accident and incident analysis had only been implemented in February 2024. The provider sent us oversight following the assessment of analysis of incidents and accidents. The analysis the provider sent us evidenced that when people fell, the staff took appropriate action to review this and make the appropriate referrals. However, this was not a full presentation of accidents and incidents, as it only reviewed falls. All other incidents including incidents of distress had not been reviewed. Where follow ups were needed, this was not recorded on the following month, for example, when people were awaiting review from healthcare professionals.

We identified that not all incidents had been logged on the new system. For example, two people were involved in an incident where staff logged that they ‘hurt others.’ This was not on the incident oversight, and the manager was not aware of the incident. The person’s care plan had not been updated, and investigations about how and why other people had been hurt had not been documented.

We received accident and incident information from the providers electronic system. One person could become distressed, and staff logged 29 incidents of distressed behaviour between October 2024 and February 2025. Despite this a risk assessment around the person’s distress had only been implemented in January 2025. This risk assessment did not provide sufficient guidance to inform staff how to support the person when they became distressed. Accident and incident oversight was poor and the provider missed the opportunity to implement improvements for people, which placed them at increased risk of harm.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

The manager informed us that team leaders completed assessments for new people moving into the service. The manager told us that the team leader made the assessment if they could meet the person’s needs, and this assessment was not based on a recognised dependency tool. Assessments were therefore not completed holistically and with consideration of staffing, and the needs and compatibility of others living at the service.

One new person had moved into the service one week prior to our assessment. We found that their care plan was limited, and guidance to inform staff how to support the person in relation to risks including mental health illness or diabetes had not been prioritised.

At our last assessment, we found that people were at risk of harm and abuse, due to a lack of robust management of people’s health needs. At this assessment we found this continued. At our last assessment, we found people were at risk from sexualised behaviour. At this assessment, we found similar concerns. We identified an incident where a person displayed sexualised behaviour to another person. Although this had been documented on an incident form, a safeguarding was not raised until we brought it to the managers attention, who was unaware of the incident. Staff told us. “We probably should check on them more when they is in their bedroom because there may be other people in their rooms.”

Staff we spoke with had mixed knowledge about safeguarding people and their responsibilities. One staff member told us, “It’s the manager’s responsibility to report a safeguarding concern,” and that they did not know who to report potential abuse to outside of the service.

The provider had a safeguarding folder where some safeguarding incidents had been documented, however the investigation and learning from incidents were not always documented. The provider missed opportunities to evidence improvements made as a result of incidents of abuse.

At our last assessment we identified that risks to people’s health and wellbeing had not been identified and mitigated, at this assessment we found the same concerns. Although a health professional gave us positive feedback about the progress of staff in managing constipation risks, we found that this risk was not being managed.For example, we identified that people at risk of constipation had not received safe care and treatment. One person had not opened their bowels for 7 days, staff only identified this on day 6 and had not sought urgent medical support for the person. Other people had periods of 4 or more days where they did not open their bowls. People at known risk of constipation did not have sufficient guidance to inform staff how to support them. Staff told us, “To be honest, I’m not really sure (how it is monitored). Sometimes we have people on our radar. We know the basics of people, but we don’t have sight of the chart. We don’t see the overall chart.” Some people were at risk of skin breakdown, and some people had wounds. Care plans to detail the current presentation of the wound, and how to escalate concerns about skin breakdown were not sufficiently detailed. Care plans contained inconsistent information on how frequently people needed support to re-position. Some people were not supported to re-position within the timeframes the provider said they should have been (every 2 or 4 hours.) We identified instances where people with wounds went for 6 hours without being supported to re-position. We found that pressure relieving mattresses were not always at the right setting and therefore were not always supportive to people, which further increased the risk of people’s skin breaking down. Other risks to people had not been assessed and mitigated, including choking risks, and people’s health needs. One person was described as getting food stuck in their throat. This person had a choking episode, which was not clearly recorded to show the actions staff took. The person’s care plan was not updated following the incident, and stated that there were no swallowing or choking incidents.

At our last assessment we identified the majority of people were living with dementia at the service, however the environment was not dementia friendly. At this assessment we found the same concerns. People living with dementia had nothing to help them orientate themselves around the service, or to their bedrooms if they became disoriented.At least 2 communal bathrooms within the service were locked from the outside. During the inspection staff were unable to tell us why. The provider informed us afterwards that 1 bathroom door was locked due to awaiting a refurbishment. However, this did not explain why other bathroom doors were locked.

The environment was tired, worn and in some places unsafe. For example, a bathroom door was broken, leaving sharp exposed edges. Within one of the toilets there was no top on the hot tap. Within some bedrooms, there was an old light cord, which often hung near where people’s heads were in bed. There were areas where changes had been made, or items removed (for example bolts removed from doors and replaced with the coded locks) but no proper making good had been done. This included in people’s rooms where walls were marked, call bells had been removed but brackets were still on the wall.

The provider had not ensured there were enough qualified, skilled and experienced staff on duty which was also an issue at our last assessment. Senior staff said there should always be a staff member on each floor. However, we found this was not the case. Staff said they did not need to be on each floor, but needed to check hourly on people in their rooms, again this did not always happen. Staff told us, “Hourly (check) is a bit long for some people. I think it should be more often.” The lack of staff put some people who could not use their call bell and had their bedroom door closed at risk. Despite accidents and incidents showing 80% of falls occurred at nighttime, staffing levels had not been reviewed.

We observed instances where there were insufficient staff. Such as no staff for 20 minutes in a lounge where 6 people were sitting and when people waited up to 25 minutes for their lunch. Staff said (on staffing levels), “Some days yes and some days no, all depends. Some days can be harder than others.”

Some staff were not learning from training as we saw them walking backwards guiding people by holding their hands which is a falls risk and a staff member standing up supporting a person with their lunch. Only 38% of staff had completed nutrition and hydration training and not all had undertaken 1st aid training. Staff gave mixed feedback about the availability and quality of the training. One told us, “We have training. It’s all the same though as it’s all done online apart from the moving and handling.” When we asked if staff could request additional or different training, they told us, “I don’t think so.”

Recruitment processes were not robust. Prospective staff had not always documented their work history and therefore references may not be requested from the most recent employer. Where staff had indicated they had a health need requiring additional support there was no further exploration to see how the provider could support the staff member.

At our last assessment, we found that the service was not clean, and the provider did not assess or manage the risk of infection. Staff were previously working in the same part of the service, whilst other areas were not clean. At this assessment we found that whilst staff had spread out and were working on different areas of the home, some areas could not be cleaned due to the wear and tear. For example, touchpoints like rails throughout the service were very worn, making it difficult to clean. Some bathrooms were very tired, and posed an infection risk, due to staff not being able to deep clean them. One person was supported in the toilet to change, however care staff left soiled clothes in a bag for over 30 minutes, and this was not picked up by housekeeping or care staff. This created a risk of the spread of infection.

People were not always supported safely with their medicines which was a similar concern at our last inspection. The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The storage of medicines had not been risk assessed, for example people had medicated creams in their rooms, which had not been assessed to ensure they were safe, which were also not temperature controlled to ensure they remained within the manufacture’s guidance. When people were administered ‘as and when’ or ‘prn’ medicines, staff did not record the outcome, if this was effective. Staff would therefore not be aware if the ‘as and when’ medicine was effective. Some people were administered ‘as and when’ medicines such as paracetamol frequently, but this had not been amended to a regular prescription. There was not always ‘as and when’ guidance for staff to follow, for example to inform staff the maximum dosage people could have in a 24 hour period. Processes to ensure that people’s medicines were administered safely were not effective. We identified gaps in people’s medicine administration records (MAR) and handwritten entries which had not been double signed by staff in line with national guidance. We asked staff about checks and audits and they told us, “We do once a week and also monthly, then the manager checks it.” These checks were not effective as they had not identified these issues, including dirty medicine trolleys.