Archived: Hevercourt

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• 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 remained inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

There was a lack of effective oversight at the service to ensure that areas for improvement were identified and action taken. Governance systems were not fully operational or effective to ensure that concerns identified within this assessment, and our previous assessment on 4 June 2024 were sufficiently addressed. Although staff told us things had improved with the new management, the new managers had not been at the service a significant amount of time. The provider had informed the new management team that the necessary improvements since our last assessment had been made. The manager had not completed any checks or audits to have oversight of the service and ensure themselves that the necessary changes had been made. We continued to find similar risks that had not been assessed or mitigated. Checks and audits had not been successful in identifying and addressing issues around risk management, the lack of guidance for staff, medicines issues and the lack of staffing. The service was in breach of legal regulation in relation to good governance.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was not a clear strategy or culture at the service, driven and embedded by the provider. Staff and leaders did not have the same vision for the service, and the risk of a closed culture remained. A closed culture can lead to harm, including human rights breaches such as abuse.

Since our last assessment, a new manager had been recruited and had been at the service for 5 weeks. Staff told us there had been some improvements; however the management team were still new to the service, and improvements were still needed. Staff told us that the manager encouraged a person out of bed, and into a specialist chair so they could spend time with others. Staff told us that the person was smiling, and “It was beautiful.” However, other people experienced poor care in relation to their health needs, which had not been identified by any of the leadership team.

At our last assessment, we found that managers had not been given the training and support to effectively manage the service. Since our last assessment, a new manager and deputy manager had been recruited and were relatively new in post. The manager previously managed the service, and the provider told us the new deputy was experienced. There was not a clear induction for the new manager, or action plan from the providers to focus and drive improvements. We found there remained serious and significant risks to people, which had not been addressed by the provider.

Staff gave us mostly positive feedback about the new leadership at the service. The manager had held meetings with people, relatives and staff. Staff told us they had seen some positive changes, for example the manager was informed staff did not have enough working hoists, and the manager addressed this. Staff told us, “I would say it’s been a good thing for residents, anything that’s raised is sorted straight away. We only had one manual and one electric hoist, now we have 3 electric hoists, it was sorted when they started.” However, there was a lot of areas where the provider, manager and deputy still needed to review, and implement positive changes, including the culture of the service and risk management. There were areas where we found new systems implemented by the management team had not been effective, for example with constipation management and identifying risks with skin breakdown. These had not been identified and addressed by the provider.

At our last assessment, staff did not feel management were approachable, and some staff told us they did not feel they could speak up. A large number of anonymous concerns were shared with CQC regarding the culture and management of the service. At this assessment staff told us things had started to improve. Staff told us of the new manager, “[Manager] has only been there a short while but they would deal with that straight away. They’re bang on the ball.”

We observed there was information around the service to inform staff who they could contact if they had concerns, and staff told us they were now aware of this information. However, all staff we spoke with told us that they felt there needed to be more staff on duty, and this had not been addressed. Staff continued to raise concerns to CQC regarding the culture of the service. The provider had not taken sufficient action to address and ensure that staff felt safe to raise concerns.

At our last assessment, staff told us they did not feel valued or treated equally. At this assessment, staff told us there had been changes since the new manager was appointed. However, the new manager had only been in post 5 weeks, and prior to this, staff were not able to share any improvements the provider had made to ensure staff felt supported. The provider had missed the opportunity to identify and act to ensure that staff had the support they needed to carry out their roles. Systems to ensure staff had clear responsibilities and roles were not effective. For example, the deputy manager and staff had different expectations about their allocation and responsibilities to check on people throughout the day. The deputy manager told us that team leaders should have checked bowel charts frequently to mitigate risks to constipation. We found this had not been done. Staff told us that some people could become distressed, disorientated and upset. There was not sufficient guidance for staff to follow to inform them how best to support people, and how to de-escalate incidents. One incident report we reviewed stated a person had, ‘sprang at me with full force, angry and upset. I ran out of the room.’ Following this incident there was no evidence that it was investigated, and that staff were spoken with to ensure that they were ok and to de-brief following the incident.Most staff had completed equality and diversity training, and the provider had policies to support people and staff from the risk of discrimination.

Governance arrangements were not robust as checks and audits had not identified concerns highlighted at this assessment and there was a lack of effective oversight from the provider to ensure improvements had been made. Although the provider had commissioned consultants to support them to make improvements we found continued breaches of regulation. The provider had not checked actions had been effectively implemented and embedded, despite all being signed off. For example, that team leaders would review care plans which was marked complete as of 31 October 2024. Risk guidance was missing or did not contain sufficient information for staff on how to support people. People’s care plans were not accurate or up to date. For example, in-consistent information on how frequently people should be supported to re-position. One person’s care plan stated they walked ‘most of the time’ but also they were not able to walk ‘due to their mobility.’ A second’s stated they were able to eat independently, but this was not the case. Similarly, accident and incidents were highlighted as an area where improvements had been made however we identified the system to analyse these was not effective. Some incidents were not fully documented and analysis focused only on falls. The provider had been completing regular visits to the service to review progress in relation to concerns raised. The visits also did not include robust oversight of improvement plans or checks to ensure that these were being implemented as expected. The lack of effective oversight led to people being placed at risk of avoidable harm.

At our last assessment we found that some people experienced delays in having their health needs met. At this assessment we found similar concerns. For example, when someone had not opened their bowels for 6 days, it was not identified by staff, and when it was it was not escalated as an urgent health concern. A visiting nurse came to the service on the day of our assessment, and we asked if staff had shared the urgent concerns with them. The nurse confirmed that staff had not. We asked the nurse if she would be concerned if a person had not opened their bowels for 6 days and they told us they would be ‘extremely concerned.’

Other referrals had been made, for example if someone fell, they were referred to the falls team or GP. However, the documentation of the follow up of this was not clearly documented. Another healthcare professional told us they had worked closely with staff to understand constipation risks; however we found that staff had not managed these risks well for a number of people. The provider did not ensure that roles and responsibilities for communication with healthcare professionals were clear or followed by staff.

There was a lack of innovative action to drive improvements at our last assessment. At this assessment we found actions taken by the provider to improve the service had not been effective and lasting. The manager was told by the provider that all required improvements had been made. However, we identified similar concerns to those raised at our last assessment on 4 June 2024. The provider commissioned a consultancy to support them to make improvements identified within our assessment from 4 June 2025. The consultancy created an action plan, which was showed to us which stated that improvements had been made in the areas of care planning for risks including skin integrity. We identified within our assessment, that skin integrity risks remained, care plans were not sufficiently detailed, and risks remained. The provider had not had sufficient oversight of the service to identify the widespread concerns that remained at the service and make proactive improvements. Although the provider told us new systems had been implemented to learn and improve people’s care. We identified these were not always effective as they did not fully consider risks to people. For example, the ‘accident and incident’ data shared with us from the provider only reviewed falls. All other incidents including incidents of sexualised or distressed behaviour were not documented, and therefore it was not clear what, if any action had been taken to learn and improve from these incidents. The provider had not identified that their systems did not consider all incidents reported within the service, and had not addressed this. The provider missed the opportunity to identify other patterns and trends and make improvements for people.