Archived: Hevercourt

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 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.

The service was in breach of legal regulation in relation to the lack of robust governance at the service.

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.

As at the previous inspection, leaders did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. We identified a closed culture at Hevercourt. (A closed culture is a poor culture in a health or care service that increases the risk of harm.) Leaders including senior care staff were not consistently demonstrating or role modelling a positive culture at the service. At this inspection, there had been no improvements.

We found the provider and the registered manager were not aways open and transparent during the inspection. After we visited Hevercourt in the evening, the following morning we spoke the provider and registered manager about the length of time a member of staff had taken to complete the previous night’s medicine administration. The registered manager told us, “The medicines were moved to 8pm to stop waking people.” This was also confirmed in an email from the provider. However, we noted from the ‘Night shift routine’ created by leaders that team leaders were required to start the medication round at 21.30.

On a call with the registered manager, we asked whether night staff were required to complete personal care to people early hours before day staff came on duty. They told us, “I came in 2 days running [at 04.00 am] and there were no signs of that [happening]. We don’t do that here.” They told us they would however expect staff to ensure people that had been incontinent would be supported with a wash. However, we saw from the ‘Night shift routine’ created by the leadership team, night staff were required at 04.00am to take all items ready for personal care to people’s rooms. It stated at 05.00 they were required to start all morning personal care and at 06.30 ‘morning personal to continue’. This indicated the night staff were required to deliver people’s morning care before their shift ended. We identified multiple concerns with people receiving their morning personal care between 04.00 and 06.30 as noted in this report.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

We found that leaders did not respond to poor performance in relation to staff which created a poor culture. We observed at 10.57 a person was asleep in bed after having just received their personal care from 2 staff. At 11.08 we observed the person remained asleep in bed. We noted there were 3 drinks on their bedside cabinet and an unopened yoghurt. We noted from their care notes that that at 10.59 the person had eaten all of their yoghurt and had recorded at 11.09 that they had drunk half of their tea, (which was not the case as most of the tea was still in the cup). This meant the member of staff had written care notes that were not reflective of the care that was provided. When we raised this with the provider, they failed to acknowledge that the member of staff was recording care in advance of this being delivered and that this would not be an accurate reflection of how much the person had eaten and drunk. They gave us no assurances this would be addressed with the member of staff.

We found there were incidents of distressed behaviours by people against staff, where staff had been hit and people had used distressed language towards staff: there were no formal debriefs by the leaders. The registered manager told us, “The team leader will be speaking to them to see if they are ok, do they need to take 5 minutes out.” If care staff have been hit by a person, it's crucial to provide immediate support and follow established procedures for reporting and addressing the incident. This includes offering emotional support, ensuring physical safety, and taking steps to prevent future occurrences. We found this was not taking place.

Leaders did not ensure that when staff spoke up, their voices would be heard. Prior to the inspection we received multiple anonymous concerns relating to the leadership and safe care at the service, including concerns about bullying behaviour from the senior leadership team.

The provider failed to create a culture where staff were able to raise concerns internally or externally without fear of retribution. We saw from the whistleblowing policy it stated that staff must always approach the manager or Nominated Individual first [with their concerns] and that ‘Failure to follow the appropriate route for raising concerns may constitute a disciplinary offence.’ Having this approach could deter staff from raising safeguarding concerns internally or externally. The Whistleblowing policy also contained out of date information around the regulator as Commission for Social Care Inspection (CSCI) which CQC replaced in 2009.

A good service will create an atmosphere where care staff feel able to report concerns and will thoroughly investigate and address such concerns within the service. We found this was not taking place.

Leaders did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider failed to address poor conduct by staff at the service. We spoke to the registered manager about an allegation that a member of staff had made an inappropriate gesture relating to a visiting professional in front of another visiting professional. The registered manager told us in relation to this allegation, “It was actioned the following day and had a documented supervision with (staff member). It wasn’t denied.” However, when we asked whether the member of staff had received equality and diversity training, they responded, “Probably thinking they haven’t done the training.” When we reviewed training matrix, we found that in addition to this member of staff a further 10 staff (including the registered manager) had not received Equality and Diversity training. Equality and diversity training is essential to create a safe, respectful, and inclusive environment for people and staff, ensuring that everyone receives the care and support they deserve. Leaders failed to do this.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider’s governance systems remained inadequate and failed to recognise a range of shortfalls in people’s care and the service. This included the lack of monitoring of people’s health and welfare as identified in this report. Leaders had failed to robustly address a poor culture and as a result this placed people at risk. The provider was still unable to provide evidence of an effective system to assess, monitor and improve the quality and safety of the services provided and to ensure they had met the regulatory requirements.

Leaders did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. External professionals raised concerns that areas they had recommended for improvements were not being taken on board. We found leaders had not shared important information to stakeholders including safeguarding concerns.

The provider did not focus on continuous learning, innovation and improvement across the service. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

Where incidents had occurred, there remained a lack of analysis of these to look for themes and trends. Leaders had not considered that incidents where people had sustained skin tears and bruising, may have as a result of poor moving and handling practices by staff. They had not considered that unwitnessed falls at night may have been as a result of how staff were deployed. There was no detailed analysis of people’s distressed behaviours to understand people’s triggers and to determine that staff were following the guidance on how best to support people.