Hebburn Court Nursing Home

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

We found breaches of the regulations relating to safe care and treatment, safe premises and safeguarding. The service and environment were unsafe due to significant risks not being robustly managed. Lifts were out of order and long overdue fire safety and electrical safety issues had not been addressed. Medicines were not managed safely. Some allegations of abuse had not been dealt with appropriately and lessons were not learnt from previous incidents to keep people safe. Some people’s distressed behaviours were ignored or not supported appropriately. This impacted on people’s safety and wellbeing.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives did not comment on the learning culture, The provider did not effectively learn from events within the home.

Due to a lack of robust and reliable data about incidents and accidents, the interim management team told us they had returned to manual incident forms. The electronic system being used didn’t provide information about lessons learnt or outcomes. Staff told us learning and messages were shared in the morning handover, we found no record of this.

The provider did not have effective systems to act swiftly and learn lessons when things went wrong. Staff had recorded 22 falls occurring between July 2024 and September 2024. Post fall observation records to check on people’s wellbeing were only available for 6 of them. Of these, none had been fully completed for the full 24-hour period. This meant the provider was unable to evidence people had received the correct care after falling to check on their wellbeing. The provider did not have a consistent approach to reviewing falls, incidents, accidents and safeguarding concerns to identify potential trends. Different formats were used to record information which made analysing data difficult. Where audits had been done, they lacked reflection and failed to explore trends to enable staff to learn from incidents and prevent them from happening again.

People and relatives did not specifically comment on people’s transition into the home. However, people were not always getting the care they needed as care plans had not been kept up to date.

The interim manager said they spoke with external professionals to ensure people had what they needed on admission. Staff confirmed, when people moved into the home, they were given information about the person’s needs.

Following recent whistle blowing concerns about Hebburn Court, the local authority had been closely monitoring the situation. External professionals were assessing people’s needs and making recommendations about what was needed to ensure they were safe and their needs met.

The provider completed a pre-admission assessment before a person moved to the home. This was initially used to develop care plans. However, care plans no longer reflected people’s needs as they had not been updated regularly.

Most people and relatives did not raise specific concerns about safety. However, people’s safety had been impacted through a lack of robust action to address safeguarding allegations.

The interim management team confirmed all staff needed additional support around safeguarding and mental capacity. They felt the current training needed improving and had arranged face to face training to achieve this.

People did not always receive safe care. There were occasions when people were placed at risk of potential harm. One person who was assessed as being at risk of choking, did not receive one to one support with eating. Despite a speech and language therapist (SALT) recommending they needed this to ensure they were safe. On other occasions, lap belts and foot plates were not consistently used on wheelchairs impacting on people’s safety.

People were not always safeguarded from the risk of abuse and avoidable harm. The provider lacked effective systems to ensure allegations of abuse were quickly reported and investigated to ensure people were safe. Serious incidents were not always taken seriously and referred to the police and safeguarding team in a timely way. This meant there were significant delays in commencing investigations. This potentially placed people at risk of continuing harm. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests (BI) and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The provider was not meeting the requirements of the MCA. There were significant delays in the provider submitting renewal applications for DoLS authorisations. This meant there were periods of time where people had been deprived of their liberty without having the appropriate authorisations in place.

People and relatives did not give any specific feedback about managing risks. People’s safety was impacted as the provider did not robustly manage risks.

Staff said they had completed training in supporting people when they were distressed. One staff member said, “We had external challenging behaviours training, we learned how to calm people down who were shouting and reassuring them.” However, we did not observe staff deploying strategies effectively to support people at these times.

Staff did not consistently follow the agreed strategies for supporting people when they were displaying distressed behaviours. They did not aways know the correct strategies to adopt or know people well enough to support people effectively when they were distressed. Interactions between people and staff were mixed, some staff were positive and supportive, whilst other staff did not interact at all.

Care plans lacked up to date and accurate information about how staff should support people when they were distressed. The provider was updating care plans to ensure they were relevant to people’s needs.

People and relatives did not comment on the environment. Their safety and wellbeing were placed at risk due to the potentially unsafe environment.

The interim manager confirmed immediate action had been taken to improve people’s safety and comfort. This included purchasing new equipment, PPE storage, visual boards to educate staff and people and continence supplies. They told us the provider was supportive when they asked for anything. Staff said improvements were needed to ensure the environment was safe. One staff member commented, “We could do with upgrading a lot of things.” Staff gave an example of a bath downstairs having been broken for over 6 months meaning people could only have showers.

The building was not well maintained. Paint and woodwork were damaged in places and some furniture needed attention. Due to the cleaning products the provider used, floors upstairs were very slippery when they were cleaned. Both lifts were out of order which meant people living upstairs had limited access to and from the first floor. This also impacted on staff who had to carry meals and laundry upstairs. Fire and electrical safety issues had not been addressed in a timely manner. Fire doors were obstructed or left open throughout our time at the home.

The environment was not safe and not well-maintained. The provider lacked robust systems to ensure potential risks the environment placed on people were assessed and managed effectively. The ability for people living upstairs to access the downstairs areas of the home were impacted due to one lift being decommissioned and the other lift being broken. Therefore, people could only go downstairs using the stairs or a stair lift. The provider had not assessed and mitigated this risk. They had also not assessed people’s ability to use the stairs or stair lift. Personal emergency evacuation plans had not been updated to reflect this change. There were continued issues with potential fire safety risks. Hazards were left in stairwells and staff used fire doors to exit the home. Actions from both the last fire risk assessment and electrical installation safety inspection were long overdue and had not been actioned. Fire safety recommendations had not been acted upon 2 years since they were identified. These related to safety equipment, signage, and door seals. The fire service completed a fire safety inspection following our visit to the home and also identified concerns, including an error on the fire alarm panel which had been outstanding for some time. The electrical installation safety inspection carried out on 15 May 2023 was unsatisfactory and identified potentially dangerous issues which required immediate attention. These had also not been addressed. CCTV use was not in line with current guidance. The provider was unable to evidence people had consented to its use or that best interests decisions were in place for people lacking capacity to consent.

People and relatives gave mixed feedback about the staffing levels in the home. A relative said, “Things are getting better but there’s not enough staff.”

The interim manager confirmed staffing levels had been reviewed and increased accordingly. Staff told us staffing levels had previously not been sufficient. One staff member commented, “Previously it was quite regular we were short staffed.”

Staffing levels had been increased following recent whistle blowing concerns. However, staff did not always respond appropriately to ensure people’s needs were met in a timely way.

Improvements were needed to ensure new staff were recruited safely. Some references had been accepted via email without the company’s official letter head and had not been verified. One staff member only had one reference instead of two, as required by the provider’s recruitment policy

People and relatives did not comment on the cleanliness in the home.

Staff confirmed they had completed IPC training which included online training for PPE, cleaning, and covid specific training. They also confirmed they had access to PPE.

The home was generally clean and domestic staff were visible throughout the home. Some personal items and toiletries were left in communal bathrooms, potentially posing a risk of cross contamination. Areas of paint and woodwork were not intact making cleaning these areas difficult. Staff had the PPE they needed, which they used appropriately.

The provider had up to date infection prevention and control (IPC) policies and procedures. Staff had also completed training in promoting good IPC.

People and relatives did not have any specific comments about medicines. However, we found significant shortfalls in medicines management.

The service could not provide up to date medicines competencies for staff who were administering medicines whilst we were on inspection. Audits from the previous manager had not identified the issues we found whilst on inspection and the interim management had not yet completed a full medicines audit. A new management team had been implemented 1 week prior to our initial visit and had started to review medicines management within the service but did feel they had not had sufficient time to improve the service. Following our inspection the management team had implemented new processes for thickener administration and topical records however we could not assess the full effects of these processes until they had been embedded into practice. The manager told us that due to changes in the integrated care board in the area the service only had limited support for medicines from the local commissioning support team which could impact the speed in which the issues are resolved in this service.

Medicines were not always stored securely and safely including controlled drugs. The appropriate checks of controlled drugs were not taking place in line with the providers medicine policy. We found overstocking of topical medicines and controlled drugs and ordering processes were not effective. We found several items which were out of date and evidence demonstrated that on some occasions people had received medicines that had expired, this placed people at risk of receiving medicines with a reduced efficacy. There was no process in place to record the administration of thickening agents to food and fluids for people with swallowing difficulties. We also found that information to guide staff was inconsistent and placed people at increased risk of choking. The service could not provide us with any records to demonstrate topical medicines administration therefore we could not be assured that people were having their medicines applied as prescribed. At a follow up visit, processes had been developed for thickener and topical medicines however we could not see the full effect of these until embedded in practice. People who received medicines covertly (medicines disguised in food and fluids) did not always have the legal documentation in place to support this decision. We also found medicines were being given without the appropriate advice from a pharmacist on how to administer. Processes in place to manage when required medicines required significant improvement. For example, we found guidance to support staff in the administration of when required medicines was not always in place, accurate or up to date. We also found no records of staff assessing the effects of when required medicines administration. Care plans for medicines were not always up to date and accurate and did not always contain information to enable staff to support people safely.