Hebburn Court Nursing Home

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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

We found breaches of the regulations relating to good governance and duty of candour. Leadership and management at the service was inadequate. The culture was not person-centred as people’s care needs were not being met. The home was not well-led due to a lack of provider and management oversight. The provider’s quality assurance systems were ineffective and had not been successful in identifying and managing potential risks and widespread failures in the quality of care. Audits lacked analysis and did not identify lessons learnt. The provider was unable to evidence duty of candour requirements for notifiable safety incidents were being followed.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The interim management team said they were committed to improving the home and this was helping raise staff morale. They said they kept staff up to date with improvements taking place.

The culture of the home was not person-centred. People’s basic care needs were not being met adequately. The provider had not been successful in creating a learning culture which meant people did not receive good care.

The interim management team said the provider was supportive and investing in the home to make the required improvements.

Leadership and management had been ineffective. There was currently no registered manager on site when we visited the home. They had left their employment the previous week, as had the deputy manager. The provider had brought in interim management from another home and an external consultant to oversee the home moving forward. They were in the process of recruiting new management.

The interim manager said there was greater provider oversight at present to help build trust with the staff team. They had seen some positive comments and engagement. They confirmed staff were encouraged to speak up and could approach both the management and provider.

The provider had a whistle blowing policy. Whistle blowing concerns had not been dealt with appropriately. For example, concerns were raised about a staff member’s conduct. Although an investigation was started, this was not concluded in a timely way. There had also been no referral made to the local authority safeguarding team.

The interim manager said they had observed some closed cultures in the home and were working with all staff to address this. They told us this was work in progress.

The provider had policies and procedures relating to equality diversity and inclusion.

The interim manager told us they had focused on people’s basic care needs and they felt “massive progress” had been made. They said they had listened to staff and encouraged input from relatives and professionals.

The provider’s quality assurance (QA) system was ineffective in monitoring the service to ensure people were safe and lessons learnt. There was a lack of management oversight from the provider. Provider QA checks were infrequent, there were only two recorded between January and October 2024. Although they had identified some issues, such as some DoLS authorisations expiring, actions were not followed up to check they had been completed. Potential risks to people’s safety were not managed effectively to keep people safe. The checks and audits completed had failed to identify and address the significant shortfalls we found during the assessment. This included addressing shortfalls in medicines management, recruitment records and person-centred care planning. Audits lacked detailed analysis to provide reassurance about action taken to keep people safe and identify lessons learnt. Care records were not always accurate or fully completed. For example, information about one person’s capacity to make decisions was recorded inconsistently in various records. Other records, such as PEEPs had not been updated to reflect people’s current circumstances and issues with the environment. The provider had developed an improvement plan to identify areas for improvement. However, this was not comprehensive enough to address all the shortfalls within the service.

The provider was working with a range of external partners to improve people’s care and make the home a safe place to live.

The provider was working with a range of external partners to improve the service following recent concerns about people’s care. This included the local authority and external health professionals. They had developed an action plan to improve the quality of people’s care.

The interim management team told us the provider did not have effective systems for identifying learning and ensuring this was then communicated to staff. They had introduced new systems to establish a baseline to move forwards from.

The provider lacked effective systems to monitor and mitigate risks associated with people’s safety, and to learn lessons to prevent situations from happening again. There was very limited analysis of accidents and incidents to allow lessons to be learnt to help keep people safe from future injuries. Falls records had not been analysed to ensure robust action was taken to prevent future falls.