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.

The service was in breach of legal regulations in relation to people’s safe care and treatment, the ways people’s medicines were managed, the safety of the environment and poor infection control practices. The service was also in breach of legal regulations in relation to people not being protected from abuse, safe staff levels and staff not receiving appropriate training and supervision.

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.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety. Lessons were not learnt to continually identify and embed good practice. At the previous inspection we found accidents and incidents of distress were not completed in detail. There was a lack of consideration around whether the deployment of staff could have contributed to the high number of unwitnessed falls during the day and at night. We found this concern still remained.

Staff were not always following the guidance around people’s distressed behaviour. Leaders were not considering this when they were reviewing incidents of distressed behaviour. This meant there was a delay in putting in place strategies or preventative measures to reduce further risks. There was also no evidence that debriefs were taking place to understand and learn from incidents.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from abuse, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. At the previous inspection we found safeguarding incidents were not investigated appropriately or reported to the local authority. We found on this inspection this had not improved. Whilst there were relatives that felt their loved ones were safe there were others that did not.

We saw from care notes there were incidents of unexplained bruising and injuries to people who were unable to verbally communicate how this happened to their cognitive decline. Leaders had not undertaken a detailed investigation to determined how this occurred. These had also not been reported to the local authority safeguarding team. The registered manager told us they would not report incidents of people hitting other people unless a bruise occurred as a result. They did not consider the impact of physical, psychological and emotional abuse. This lack of recognition of what constitutes alleged abuse meant that people were being placed at risk of further abuse.

The providers safeguarding policy stated, ‘Due to interpretation of what constitutes a safeguarding case, the home has made a decision to refer ALL suspected safeguarding’s to the local authority safeguarding team for them to decide whether each case should be taken further.’ We found this was not taking place.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe and supportive. Since the previous inspection there has not been sufficient improvement around the management of risks.

There were people that were at high risk of malnutrition and were required to be weighed weekly. However, leaders were only reviewing people’s weights monthly. We also noted that where people were required to have milkshakes to increase their calorie intake, staff were always not recording when these had been given. We found people continued to lose weight. One relative told us they were concerned that their loved one was not supported to eat their meal, and we observed examples of this during lunch with other people that required support. This placed people at further risk of malnutrition. Another relative told us, “There doesn’t seem to be anyone recording what (person) is eating, no one has checked what (person) is eating.”

Other health risks associated with people’s care was not being managed well including (but not limited to) the risk of dehydration, falls, choking, moving and handling and distressed behaviours. We found this had not improved since the last inspection.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment supported the delivery of safe care.

We observed the bed rail bumper on a person’s bed was too large for the bed rails. Poorly fitted bumpers can cause entrapment issues themselves. If there is involuntary movement, the person may end up in a fixed position with their face against the bumper, this may cause an asphyxiation risk. We asked the registered manager to address this. We observed in another person’s room, their pressure mattress monitor was not fixed to the bed and had been left on the floor which was a trip risk. In 1 person’s room there was a portable fan and profiling bed that showed the electrical checks that should be undertaken yearly had not been completed since 2022 and April 2024 respectively. These tests provide reassurance that electrical appliances are safe for use. The provider failed to do this. We observed the commodes that people used in their room were old style metal framed which would have been uncomfortable for people.

At the previous inspection, the provider did not make sure there were enough qualified, skilled and experienced staff. They did not work together well to provide safe care that met people’s individual needs. We found on this inspection this had not improved.

We found there were not sufficient numbers of staff deployed to ensure safe care at night. Leaders and staff told us that at night, there were 4 staff (including a team leader). They told us staff were not required to base themselves on all floors and would only go onto the upper floors every hour or when people used their call bells. The provider told us, “It’s an unrealistic expectation to expect staff to sit all night on a chair in the corridor.” However, we saw from the providers falls report that between the 5 May 2025 and 1 July 2025 there had been 14 unwitnessed falls that occurred during the night shift. This included falls for people that were on the upper floors and were unable to use a call bell due to their cognitive decline. The provider failed to consider whether the deployment of staff at night could have prevented these falls. In addition, the provider confirmed that call bell response times during the night shift was expected to be 5 minutes. We identified over 31 occasions over 1 week where calls bells took longer than 5 minutes to respond including up to 20 minutes on 1 occasion.

We found there were not sufficient staff to support people during the day. One relative told us, “I think the staff are stretched, they always seem to be really busy.” We found the majority of people were being brought into the dining room for the duration of the morning. Where people attempted to walk out of the room, we saw people were often brought back in and encouraged to sit back down. One member of staff told us of a person, “Staff try and keep (person) in the communal areas as there is always somebody around.”

During lunch there were multiple people that required support with the lunch however staff were unable to do this as they were too busy. Although staff were bringing people drinks, they were often left untouched. As such people at times had several drinks placed in front of them as staff did not have sufficient time to support people to drink them. We could not be assured people were supported with their hydration, especially during periods where it had been very warm. One relative told us, “Yesterday this (person) was left to eat lunch on her own, (person) was calling out for help, one of the carers said (to person) ‘Do you want it or don’t you want it because I’m busy’. There are not enough people (staff) in here.”

Whilst there were staff who received training, this was not effective to ensure they were competent to deliver care. We observed 2 members of staff attempting to drag lift a person by placing their hands underneath their arms. This technique puts a dangerous strain on the shoulder of people, inevitably causing discomfort and often injury. We saw from the training matrix e-learning moving and handling training was out of date for 4 staff including the registered manager. We saw that face to face moving and handling training had not been completed for 7 staff.

Whilst there were staff who received training, this was not effective to ensure they were competent to deliver care. We observed 2 members of staff attempting to drag lift a person by placing their hands underneath their arms. This technique puts a dangerous strain on the shoulder of people, inevitably causing discomfort and often injury. We saw from the training matrix e-learning moving and handling training was out of date for 4 staff including the registered manager. We saw that face to face moving and handling training had not been completed for 7 staff.

In addition to this, we saw from the training matrix that out of 50 staff currently working, 6 staff had not received Food Hygiene training, 5 staff had not received Fire Safety training and 8 staff had not completed Falls Awareness training. We found 6 staff had not received First Aid training and Dementia training and 5 staff had not completed Health and Safety training and ‘Behaviours that challenge’ training.

According to the providers supervision matrix, 3 staff had not had any supervision or appraisal since November 2024. We found 11 had only received 1 supervision since November 2024 despite the supervision policy stating that 3 supervisions and 1 appraisal needed to take place each year. Regular supervision helps ensure staff are competent and confident in their roles, meeting the standards required for their practice. Leaders failed to ensure this, and we identified multiple areas of poor staff competence as noted throughout this report.

Leaders did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Staff were not always following good infection control practices. We found on the second visit to the service the sluice room was unlocked and there was a strong malodour coming from the room. In the sluice there was dried faeces down the sides of it and there were spots of dried faeces in the sink that staff were to use to wash their hands. In one person’s room, there was dried faeces on the lid of the commode and in the commode bowl. In another room there was a strong smell of urine in the commode bowl and a faeces stain on the lid. This placed people at risk of getting infections.

In addition to this we observed a member of staff coming out of a person’s room with a red bag of soiled clothing with no gloves on. They placed the bag into the laundry bag into the bathroom opposite and returned to the person’s room without washing their hands.

However, there were other areas to the service that looked clean and well maintained. We observed staff served food wearing appropriate aprons and gloves.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We identified on the previous inspection that there were multiple gaps in people’s medicine administration records (MAR) and there was a lack of ‘as and when’ guidance for staff on when to administer pain relief. This is particularly important given most people had advanced dementia and may not be able to articulate when they were in pain. These concerns still remained as there was still a lack of guidance in place. This meant there was a risk people were not always receiving their medicines when needed.

We observed controlled drugs were not counted as the white boxes (that were taped shut) they were delivered in from the pharmacy had not been opened. This meant that the actual number inside each box had not been checked when booking in the medicine, and when undertaking daily checks which noted the quantity. There was also a risk that the glass ampoules could have become damaged inside the white box. In addition, we found there had not been controlled drug check forms completed on 4 occasions.

We found the temperature charts for the medicines rooms were not always completed. In addition, the fridge temperatures had exceeded manufacturer’s instructions to ensure the medicine was kept at a safe temperature.

Where people were prescribed topical medicines (prescribed medicated cream) there was no indication on the Medicine Administration Record (MAR) of where the location of where the cream need to be applied. Where people required eye drops there was no information on which or both eyes required the medicine. It is crucial to have clear instructions, body maps, and proper documentation to ensure safe and effective application of medicine and administration of eye drops.

There was a lack of a system in place for monitoring the Medicines and Healthcare Products Regulatory Agency (MHRA) alerts and recalls of medicine. When asked if this was undertaken a member of staff told us, “Very rarely we do.” This was despite the providers medicine policy stating this needed to be done. This placed people at risk as they may be administered medicine that was not safe.

We found there were gaps in MAR so the provider would not be assured people had received their medicines or the correct dosage. This placed people at risk of not receiving their medicines where required.