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

The majority of the people living at Hevercourt were unable to reliably communicate their needs and choices due to cognitive impairment. Therefore, their safety relied upon risk management, monitoring of their condition and learning from incidents to anticipate needs and improve the safety of care. We found people's condition was not robustly monitored, such as weight loss. Food and fluid intake was also not robustly recorded to enable a safe response to weight loss for example. We saw evidence of some deterioration amongst some people which had not always been acted upon. We found there had been an increase in incidents and accidents, particularly falls, in the afternoons but no responsive action taken to improve safety for people. Staffing levels impacted the quality of care and a reduction in staffing levels in the afternoon contributed to increased incidents, less frequent support and unsafe support practices. Staff training was not always up to date and there was little evidence of an action plan to address this or mitigation of risk in the meantime.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

While the relatives we spoke to expressed that they were generally happy with their loved ones care, our assessment found care did not meet the expected standards: people did not always receive adequate support to manage their risks, and this had led to people not receiving support when they most needed it. People had experienced an increase in incidents and accidents in recent months. We saw that patterns in people experiencing incidents and accidents had not always been identified by the provider to learn from them.

Investigations of incidents and accidents were not robust. Staff told us some adjustments were made for people in response to incidents but they were not confident they had always been updated to reflect changes in need. One staff member told us, “I’m not sure if I get told of any changes. Another staff member told us, “I think our handover could be a lot better and detailed sometimes.” We saw no evidence of action taken as a result of learning from incidents despite the Registered Manager telling us, “I look at all the accidents and incidents, what time they happened and I will take action if I pick anything up”.

The provider did not have processes or systems in place to promote a learning culture. There were no systems or action in place to continually identify and embed good practices across the service to address patterns of risk. For example, we found that despite medicine errors having been reported and investigated, we observed continued unsafe practice during the assessment. Care records detailed incidents of risk that had not been included in incident and accident records, nor responded to effectively by staff. There were missed opportunities to learn and improve care and safety for people using the service. Concerns raised by staff to the registered manager had not always been appropriately investigated and responded to with actions to improve care delivery for people.

While the relatives we spoke to expressed that they were generally happy with their loved ones care, our assessment found care did not meet the expected standards. Although people were sometimes referred to health professionals such as district nurses for new and existing health conditions, people could not be assured that staff or the registered manager would always make appropriate referrals. For example, people who were at high risk of serious harm to their health from dehydration, constipation, malnutrition and pressure areas had not received appropriate care and treatment. Because of this people had experienced harm and were at risk of ongoing harm.

Leaders did not ensure people had a safe transition into the service. The registered manager told us that beds were not empty for long before new referrals were accepted and that recently four people had been admitted in quick succession. One staff member told us, “We admit people far too quickly, we need to get to know people.” Another staff member told us, “We had a lot in one go recently, we didn’t get a chance to get to know them”. Despite the registered manager telling us people were supported when admitted to hospital along with key information about their care, people’s records did not always contain key updates on their risks, and therefore people could not be assured their hospital pack was a true reflection of their current needs. Staff and leaders had a poor understanding of people’s needs, and had not recognised deterioration in people’s health conditions or taken action and raised concerns with health professionals to ensure people received necessary care and treatment. Because of this, people had prolonged periods where their health conditions had not been treated: this caused people harm.

Partners told us people’s safety was not always assured because of a lack of skills in the leadership team. They told us this had contributed to some shortfalls relating to management of people’s medicines and people’s end of life wishes. When partners were contacted by the service, they told us there were good processes in place to acknowledge and implement recommendations. However, we found significant concerns with leaders not recognising when referrals needed to be made to partners about people’s health. This led to people not being safe, or having the right care and treatment to meet their needs.

The provider and registered manager had failed to ensure there were robust processes in place which ensured people’s safety. Despite people’s having an initial assessment of their care needs when they first moved to the service, no consideration was given to the frequency and speed at which people moved in, or how staff were supported to provide care and support to a number of people, some of whom had multiple complex needs. In addition to this, processes to continually monitor, review and assess people’s needs were poor. When people needed support from healthcare professionals, referrals were not made and people suffered harm. For example: systems to monitor signs of deterioration such as weight loss or skin integrity had not always been used effectively to provide people with an adequate and prompt adaptation to their care. People at risk of malnutrition and dehydration did not have their ongoing eating and drinking robustly monitored and appropriate referrals had not always been made to relevant health care professionals.

People were largely unable to communicate their experience. However, we saw that staff and leaders had not been proactive in managing people’s safety. People had remained vulnerable to harm through poor monitoring and neglect. People who experienced distressed behaviours and who had known risks of significant self harm did not have any risk assessments in place to mitigate these risks, or have any guidance in place to enable staff to support them safely. Other people at risk of harm from sexualised behaviour from other people were not protected: there were no risk assessments or guidance in place to ensure people’s safety. There had been an increase in safeguarding concerns in recent months: people had been harmed and were at risk of abuse but incidents were not always recorded as such which meant there was no opportunity to put in place actions to reduce further incidents.

The registered manager told us they had made all the relevant referrals to the safeguarding team. Staff told us they had completed safeguarding training online. However, this assessment identified that staff and leaders did not always recognise abuse and harm, and had not made appropriate referrals, or taken action to keep people safe from harm. There was a failure by leaders to proactively manage risk before incidents occurred. Staff did not always feel that their reports of concern were responded to appropriately by the registered manager. One staff member told us, “I don’t think things are dealt with importance or priority”. Another staff member told us, “Things are not always done to take action”.

People were not safely supported during our assessment. People at risk of falling or of choking on their food were left unsupervised whilst exposed to the associated risks. We saw that some people who needed support to mobilise were left in their bedroom without the ability to call for support. This meant that people were at risk of harm as a result of neglectful care.

There were inadequate process in place to ensure people were protected from abuse and neglect. Leaders had failed to have robust systems in place to ensure a proactive response to safeguarding people and preventing deterioration of people’s health, or to ensure people were safe from avoidable harm. The failure to have systems and processes in place meant people had suffered harm, and were at risk of on going harm. For example processes neglected to account for the additional needs of people vulnerable to harm from falls or choking, or harm from others.

People were experiencing deterioration of their health conditions but we saw no evidence that people or their representatives had been involved in how people's risks were managed. People were at risk of skin deterioration and needed support to reposition in bed and others were at risk of weight loss needing their intake to be monitored and support to eat and drink safely. People were not experiencing support to mitigate these risks, and in many instances, there was a lack of guidance for staff to ensure people's risks were safely managed.

Staff did not always read risk assessments. One staff member told us, “I have never seen a risk assessment, I wouldn’t know what one looked like.” Another staff member told us, “No I don’t read them but they do tell us what we need”.

We observed that risk management guidelines for significant risks were not always clearly detailed, nor followed by staff. For example, we saw people were left unsupervised at mealtimes when their risk assessment stated that staff should observe them whilst eating. We also saw that people who had an identified risk of falling and needed supervision, were left unsupervised. We saw that staff were using one person’s prescribed fluid thickeners to support others with the same need. We observed that people could not always reach their call bell to gain attention if they needed support.

Risk assessments were in place for people where a risk had been identified, however they were not always accurate or detailed enough for staff to know how care needed to be delivered to mitigate risks. For example, risk assessments stated that a person may present aggressively or walk into other people’s rooms, but there was a lack of guidance for staff in how to manage this. Leaders had not ensured staff understood and followed risk management plans. Emergency evacuation information in case of a fire was missing for some people and there was information for people who no longer resided at Hevercourt. Fire safety services would have difficulty in ensuring people were safe in the event of a fire.

Most people who lived at Hevercourt were living with dementia and significantly impaired cognition. Relevant adaptations had not been made to the home to support those with memory loss, disorientation and impaired coordination. There was a lack of pictorial prompts and visual aids to promote safety and to help people find their way. Although relatives did not raise any concerns for the environment being unsafe, they told us that rooms were not always big enough for the required equipment meaning people had to move rooms. This risked further disorientation for someone living with dementia. One relative told us “Her mobility deteriorated so staff suggested she move to a bigger room, so they had space to take in a hoist”.

Staff told us the environment hindered their ability to support people who needed to be observed mobilising to ensure their safety. One staff member told us, “I like upstairs as it’s a straight line, the others are nooks and crannies, and you can’t see people”. Staff felt the environment did not support people to be as independent as possible. One staff member told us, “It’s not a dementia home, it’s not designed for people with dementia”. The provider failed to recognise the benefit of environmental aides and told us, “The home is laid out linearly and most staff ... are on duty in these areas. In our opinion, directional signage in these circumstances would be of little use.” During the assessment we found that environmental issues had been identified but not always fed back to the maintenance team. The provider told us "I have just spoken to maintenance and they did not know about the kitchen ceiling. This is [staff members] writing in the audit and [they] did not know to write it in the maintenance book, but they are repairing it now".

The service primarily supported people who were living with dementia, however we observed that the environment did not cater to dementia related needs. There were no purposeful opportunities for sensory stimulation and very few adaptations to orientate people to their environment. The first aid boxes had out of date items in them. We observed obstructions and hazards in the corridors and items such as wheelchairs in bathrooms. This posed a hazard to people mobilising safely or a potential cause of injury should someone fall and hit them.

Processes to identify environmental risks were not robust enough to act on concerns thoroughly and promptly. There were no maintenance audits or building inspections completed to review the safety of the environment. Staff were required to write a note in a maintenance book when they had seen a need for maintenance support. However, we saw maintenance issues highlighted in the kitchen audit which had not been brought to the attention of the maintenance team.

When asked if they felt there were enough staff, one person told us, “They could do with more. The people who shout, do it to get attention and the quieter ones get less.” While the relatives we spoke to expressed that they were generally happy with their loved ones care, our assessment found care did not meet the expected standards: there were not enough staff to ensure people’s safety, and staff did not have sufficient knowledge or skills needed to keep people safe.

The provider and registered manager had failed to keep people safe because they had not ensured there were enough staff on each shift, or ensured that staff had appropriate training to meet people’s needs. This failure had significantly impacted on people’s safety. Staff told us the provider had recently reduced staffing levels in the afternoon, feeling there were enough staff. However, several staff raised concerns about the impact of staffing levels. One staff member told us, “Sometimes people who need two staff are making do with one”. Another staff member told us, “In the afternoon the numbers go down by 1. We have a team leader in the lounge but that leaves 5 to go on 3 floors and reposition people. 1 member of staff is at times doing this on their own”. People who needed support to reposition, required two staff to do so safely. Staff felt people’s complex needs were difficult to manage due to staffing levels. One staff member told us, “Mistakes are made as there is so much to do, our dependencies are so high, palliative care, so much dementia, the pressure is immense. Staff are shattered and its non-stop, they are run ragged.”. Another staff member told us, “We have a lady on unit who is swinging the call bell and hitting the wall with it because she has been left too long.” The registered manager told us the team were fully staffed and there were no agency staff needed. The provider told us they were proud that they had not used agency staff for four years. The registered manager stated they calculated how many staff were needed by totalling the hours from each person’s care plan: “On each care plan there is a dependency tool. That doesn’t help you at all, but I know how I work it out.” Our assessment identified that care plans were out of date and inaccurate, and in some instances were not in place.

We observed multiple instances of insufficient and unsafe staffing which impacted on people’s safety: at lunchtime there were not enough staff to provide the care required as detailed in people’s care plans: people who were at risk of falls or choking were left unsupervised in the dining area. Staff were busy and we saw minimal interaction for people who required assistance and support, especially those who remained in their rooms. We observed people who had been assessed as ‘very high risk of falls’, were left alone in a lounge for the entire lunch period. In addition, people who may be a risk to themselves or others due to distressed behaviour, including being aggressive towards people they live with, was in a lounge with other people without any staff support for the entire lunch period.

Processes to ensure safe and effective staffing were inadequate and impacted on people’s safety. Records of staff training showed that not all staff had up to date training for areas relating to people’s specific needs. There was a lack of an action plan to address this. There was a lack of evidence of how staffing levels had been calculated. The provider and registered manager had not accounted for staff auxiliary duties, the layout of the building or other variables in addition to hours which had been calculated for individuals. Domestic staff were not employed in the afternoon and so care staff were required to attend to cleaning duties as required. Staffing levels were negatively impacting people’s care. We saw from records that the frequency in people being prompted to drink fluids, for example, reduced in line with staffing levels and people were not always sufficiently hydrated. Staff did not receive appropriate support to enable them to carry out their role safely: they had received minimal training, and had limited input into any discussions about how to improve their performance, or how to improve the service people received.

People living at Hevercourt were largely unable to verbally communicate their experience. However, we saw that people were using commodes with longstanding discolouration and touchpoints and windowsills were unclean. The environment was not clean and hygienic. This placed people at increased risk of acquiring infections and other health related conditions from living in an environment that was not clean.

Staff felt the environment fell short of hygiene standards. Staff told us, “The cleaners do clean but there are no cleaners in the afternoon. We need them here all day to at least clean the handrails and touch points.” Another staff member told us, “The cleaning is shocking, tea gets spilled and not cleaned up.”

We observed the environment to be unclean in multiple communal areas such as the dining room floor and touch points. We observed the cleaning staff to be working together on the same floor and not dispersed throughout the care home. However, we saw that staff were mindful of infection prevention when providing care. They appeared to be using the correct personal protective equipment when supporting people and disposing of it appropriately.

The provider and registered manager did not have effective processes in place to assess and manage the risk of infection. The failure to have effective processes in place put people at risk of harm. The registered manager and provider had failed to notice people’s environment was not clean, and had failed to ensure appropriate numbers of domestic staff were employed, and deployed appropriately. Although there were cleaning schedules in place which were signed when they were completed, there was no system in place to check the quality of the completed tasks or to audit the cleanliness of the environment. Most staff had completed the infection prevention and control training and were supporting the domestic needs of the care home since domestic staff were only employed to work in the mornings. Care staffing levels had been reduced in the afternoons: this meant there were inadequate levels of staffing to safely meet people’s assessed needs, or ensure people’s environment was clean, hygienic and free from the risk of infection.

People did not always experience safe support with their medicines. We observed staff to record medicines administered before giving it to people during the assessment. People had experienced errors with medicines and although this had been responded to on a case-by-case basis, action had not been taken to improve systems and fully address risks to all people. Relatives told us they felt informed about people’s medicines and any changes which were being made. One relative told us, ““If there are ever any changes to her medicines, they let us know. They are good at keeping us updated”. They felt confident that the service worked with health partners to ensure people received the most appropriate medicines. One relative told us, “Between the care home and the mental health team they have managed to get her medication correct now”.

We fed back to the registered manager during the assessment that we had observed some unsafe recording of medicines. They confirmed this should not be happening and responded immediately. The registered manager confirmed they are supporting all staff to receive up to date training in the administration of medication and undertaking further competency assessments.

Staff were signing for administering medicines who did not have current and up to date training and we saw records were not being completed safely. These errors were not being identified by the manager other than when incidents had occurred, been reported and investigated. There were processes in place to assure the provider that the correct quantities of medicines were present and they were counted regularly. Medication administration records clearly displayed any allergies people had.