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

The registered manager had been registered since September 2022 but a change in deputy manager had impacted support for the registered manager in the leadership of the service. The registered manager did not receive adequate support from the provider to effectively monitor and improve the service. Learning and improvement of the service was impacted by limited quality assurance and oversight measures. Staff were discontent and concerns around freedom to speak up limited the providers insight into operational concerns. There was a fractured culture within the staff team and a failure to collaborate and consult with staff, or to analyse staff engagement and conflict resolution to identify inconsistencies.

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.

Staff told us their experiences working for the service were not equal. One staff member told us, “I've noticed some staff members like to do what they like and when they are told to do something they get quite abrupt and mouthy back to you.” Other feedback demonstrated examples of a fractured culture and discontent between staff members. In response to several whistleblowing concerns raised with the CQC, the provider told us, “We take these seriously as they have a serious effect on the well-being of senior staff”. The provider had begun speaking with staff but there was not a robust plan in place to address the culture. They told us, “It is difficult to address organizational issues when there is no apparent problem”. Within a summary of the staffing team, the provider told us, “They all work very closely with each other”. There was a lack of understanding and acknowledgement from the leadership team of the issues raised during the assessment.

An employee survey had been conducted in May 2024 which showed a mixed response in how staff felt in the areas of ‘colleagues’ and ‘managers and supervisors’ indicating a fractured culture within the service. Records of one-to-one meetings with staff were focussed on maintaining performance and there was no evidence of a collaborative discussion about the direction or culture of the service. Records of discussions with staff about concerns raised were of a punitive nature rather than supportive or progressive.

Staff raised concerns that there was a lack of capable senior presence at evenings and weekends. One staff member told us, “I’m doing this weekend but the other weekend don’t always have seniors”. The provider told us that there were staff with childcare commitments in the afternoon and this impacted staffing. They told us “There is a lack of senior staff in the afternoons. We have been pushing for [Registered manager] to do more weekends to make up for the time in the week. Some days are better staffed than other days and we need more of a balance here. There is no easy way.” The registered manager felt she was capable in managing the service. They told us, “I would not say I cant lead the home or that that’s it’s not well led, as I believe it is”. Staff felt the registered manager could be supported better. One staff member told us, “I feel [registered manager] should have more training”. Staff did not always feel their need for support would be met with compassion. One staff member told us, “We are so tired and run down, sadly we are too timid to say you don’t feel well”.

The registered manager had received no managerial training. Their one-to-one meetings with the provider were not recorded and so we were unable to see where their performance and learning and development needs had been discussed. Staff meetings showed there had been some praise of staff and recognition of achievement. However, there was little staff voice recorded and it was not evident that staff were able or encouraged to contribute towards the running of the service or that their opinions were valued. One to one meetings and meetings as a result of a cause for concern were not audited to provide insight into how staff were managed and whether there was equality and effective outcomes.

The registered manager told us, “I have put a staff survey out recently. If there is anything I am doing wrong, I need to know.” “I still have to say to them sometimes if you’re not happy with the team leader then go to deputy, then me, then owner. If not, you have CQC”. Staff told us they did not always feel listened to and some staff told us they did not feel management were approachable or confident that matters would be addressed confidentially and sensitively. One staff member told us, “I have brought up a few on cause for concern...We are told to speak to them but I feel its management job to address it.” Another staff member told us, “I have heard that people have gone to management about a member of staff and then most of the home know about it”. Although staff knew the line of delegation for reporting concerns, staff reported a lack of confidence in speaking up to the provider. One staff member told us, “I don’t know the owners, they never speak to us.” Another staff member told us, “What annoys me is [providers] don’t talk to residents. They don’t know staff” The staff survey from October 2023 highlighted that staff wanted the handover to be more detailed. Staff feedback during the assessment included “I think our handover could be a lot better and detailed sometimes.” And “There could be a bit more information on handover”. This demonstrated that when staff had spoken up, changes had not always been made.

We saw there were processes available to staff to encourage them to speak up and to be able to do so anonymously. There was a whistleblowing policy in place. Although staff had not received training relating to speaking up, it had been encouraged by way of promoting ‘Cause for Concern’ forms. However, these were not consistently used by staff. We saw records showing how ‘Cause for Concern’ forms had been responded to. Where staff had raised concerns for colleagues performance, the follow up action did not include learning or robust action other than talking to staff about their performance. We saw that there was often a punitive approach rather than collaborative or improvement focussed.

Staff gave very different accounts of how they felt they were treated and did not always feel it was equal. One staff member told us, “I don’t feel valued at all, you can tell (the owners) don’t want to be here”. Whereas another staff member told us, “I can find [registered manager] very approachable, she was my agony aunt when she was the deputy manager. I feel I can go to her if I need a chat .” The provider told us that they aim to accommodate different staffing needs and promoted flexible working where staff had childcare commitments. Staff told us, “When I needed to go home because my daughter was unwell, [registered manager] told me to go and she will sort it”.

Within the staff team, some had caring responsibilities and some had health diagnoses which would benefit from work adaptations, flexibility and support. We saw that adjustments to rotas had accommodated personal commitments for some people. However, one to one meetings with staff did not always show that two way wellbeing and inclusive discussions had taken place.

The registered manager recognised that there was a lack of evidence of oversight. They told us, “I can answer any question, but I've got to show it. I need to display it”. They told us "I like to be out there with the people, paperwork isn’t my thing". The registered manager told us they understood people’s needs and told us they felt they knew what was happening in the service, even if it wasn’t necessarily documented. The provider told us they felt the care home was running well. They told us, “We have 2 care homes and for us it is about 'how calm does this home feel?'. We always get the sense here that it is under control.” This demonstrated an inaccurate understanding of the quality of care; unaligned with the evidence we found. The provider told us, “{Registered manager] has NVQ level 5 but besides that no management training and operates at one hundred miles an hour”. The provider told us they did not know where to source managerial training. When asked about the support provided to the registered manager, the provider told us, “Maybe we haven’t spent as much time with [Registered manager] as we could.” The provider acknowledged that an audit of call bell response times would be useful.

There were not always audits in place, but where there were they did not hold enough analytic information to sufficiently learn from and make improvements with a rationale. For example, training audits were a list of completed training and handwritten notes stating “addressed with staff”. Audits of medication administration records had identified some errors but there was not always a record of detail of the issue or action taken to improve the service for everyone. We saw a mealtime experience audit with tick boxes which lacked detail. The tool was unable to provide examples of good or bad points to enable reflection and adapt care to improve people’s experience. Although the registered manager analysed accidents and incidents each month, there was no audit around themes and trends, and people’s risk assessments had not been updated to reflect a change in their support needs. In latter months, the registered manager had written on the covering page what action they had taken to incidents, but there was little evidence to show they were using the information coming from the analysis to improve the service for people and reduce the number of incidents. Handwritten actions on documents made it challenging for other staff to provide continuity if they were to support in the absence of the registered manager . The concerns we identified within the assessment had not been identified by the provider, indicating that the governance systems were not adequately providing oversight and assurance of the service.

People did not experience a consistent approach to their healthcare needs. Whilst some people were referred to an optometrist, chiropodist, district nurses and the GP, not everyone was referred to healthcare professionals when they needed care and treatment: some people experienced significant health deterioration with no referral made by the registered manager to appropriate professionals to ensure they had the care and treatment they needed. When referrals were made, people did not always experience a change to their care when concerns had been raised by professionals, which led to further deterioration in their health condition. Relatives told us they had been invited to provide feedback to the provider. However, they were not always familiar with who the manager was.

Staff and leaders did not have seamless links with partners or communities. Despite having links with some external bodies for example, district nurses, there was a fundamental lack of understanding from leaders about when it was necessary to share information about people’s emerging or deteriorating health conditions. When district nurses provided advice and guidance about people’s health, this was not consistently followed by staff, which impacted on people’s safety. The provider told us “District nurses have provided some training. District nurses are a big part of our life”. Staff were unable to provide examples of community engagement and although relatives visited individually, there were no examples of coordinating a community wider than the service.

Leaders did not always ensure collaborative partnership working which focused on shared learning and good outcomes for people. We received a mixed response from partner agencies. One partner told us they had raised concerns about the safety of the environment, such as obstructions in communal areas, but had not been confident such issues had been addressed or learnt from since further visits had proven those same issues to be unresolved. Another told us they had raised concerns about how people were supported with at the end of their life, and concerns about people’s medicines. One professional told us that staff were vigilant in calling upon them when they felt there was a concern. They told us that sometimes staff would call when it was not always necessary but they “would rather them do that than not call”.

Leaders had ineffective processes in place to refer people to health professionals and engage in a meaningful way with partners. People’s health needs were not always recognised by leaders, and therefore people were not referred when they needed to be. When people were referred, there was no system in place to audit the effectiveness of advice and guidance from healthcare professionals, and we found several instances of where guidance had not been followed, and people’s health had deteriorated. There were inadequate processes in place to share learning with staff to ensure people received the right care and treatment which led to good and improved outcomes in people’s health: there was a recording sheet for professionals to provide information. Although the registered manager transferred this to the handover, the information was not robust enough to enable staff to feel confident in delivering adapted care.

The registered manager recognised a need for improvement. They acknowledged gaps in their knowledge and experience but as yet had not taken action to improve upon it. There was a lack of recognition of some of the concerns raised during the assessment. When it was brought to the attention of the provider that first aid contents had expired, they told us “I've never quite understood the purpose of that.” When we raised concerns we had found, there was a lack of recognition for learning and improvement. The provider told us, “We have been in the business for 20 years and feel we know what we are doing from a process point of view” Staff told us feedback which could support improvements had not been acted upon. One staff member gave an example and told us, “None of us have name badges and relatives ask about this all the time.”

There was a lack of evidence of innovative action to drive improvements. The provider was not using external research to help improve the service such as research relating to dementia friendly environments. There was no service improvement plan in place, however the provider was made aware that because of the assessment outcome, we would require an action plan for improvements of the concerns found during the assessment .