Hazelgrove Court Care 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement and identified a regulatory breach in relation to the oversight of infection prevention and control procedures. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

A new home manager had been appointed who came into post part way through the assessment. Together with the regional manager they were working to develop a culture based on openness and honesty. Staff spoke about improvements to learning that had happened recently. One staff member said, “I have never felt listened to up until now, we have an area manager who listens.” Supervision meetings had been used as a learning event following an incident. We were told events like this would continue to happen following incidents, such as falls, to ensure staff learning.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

Systems were in place to assess and manage risks. Risks relating to choking, skin integrity and falls, for example, were identified and mitigated. Staff knew people well and were able to support them appropriately, however, some care plans contained inconsistent information in relation to people’s needs, particularly in relation to medicines, percutaneous endoscopic gastronomy (PEG) care, and bowel management. Whilst we did not find any evidence people had been harmed, omissions and inconsistencies in records placed people at potential risk. People, and their relatives told us they felt safe at the home and were involved in their care.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Safe recruitment practices were followed. There were enough qualified, skilled and experienced staff to provide care that met people’s individual needs. Some staff said they felt there were not enough staff to meet people’s needs. We raised this with the regional manager who explained they were working with the new home manager to ensure effective staff deployment and a whole home approach to staffing was being implemented. Staff had access to appropriate training, support and supervision meetings.

Systems to assess and manage infection prevention and control were now in place. Some shortfalls were identified during the assessment, including in the medicines room which the regional manager immediately addressed. A redecoration and refurbishment plan was in place which would improve the environment for people. A ground floor bathroom had been converted to a hairdressing room, requiring people to use the first-floor bathroom if they wanted a bath. The regional manager said steps were being taken to reinstate the ground floor room as a bathroom.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines were stored safely and securely. However, some storage areas for medicines were dirty, cluttered and untidy. We raised this with the regional manager and it was rectified immediately. Medicines records generally assured us that oral medicines were being appropriately administered. However, people did not always receive their pain relief medicines at lunch time due to the morning medicines round running over time. This placed people at risk of experiencing unnecessary pain. A process was in place to manage how creams and ointments should be administered and recorded. However, this was not robust. No body maps were in place to support staff in where to apply the creams and ointments. Processes to manage the administration of thickener required improvement. Records were inconsistent and did not always match the correct level prescribed and written in care plans. We looked at one person’s records who received medicines via a PEG. Whilst the care plan was in place, with specific instructions regarding medicines flushes, reports demonstrated this was not always followed. Several audits were taking place, but they had not identified the issues found on inspection. Audits provided after the inspection demonstrated the provider had continued to identify further issues and a plan was in place to rectify these. Post inspection site visit, the service had continued to make improvements, however, the effects of these could not be fully measured until embedded in practice.