Hazelbrook Christian Nursing Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The provider was in breach of the legal regulations relating to need for consent.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

There was evidence of people’s needs being assessed when they first moved to the home; some people told us their relatives were involved in this process. However, one person told us about a poor experience when they first moved into the home; they said, “I was in a bad way when I came here. They [staff] didn’t talk to me, and I was in pain with my catheter. They [staff] all came in shouting at me telling me I had tampered with my catheter and made things worse. I was in tears, I felt like no one believed me that my catheter was hurting me. They [staff] said I had pulled my catheter out myself. Eventually they [staff] sorted it out after I had made a big scene over it.”

Some care plans in general lacked important information about people’s care, for example regarding communication, eating and drinking and personal hygiene. An electronic system was used to record care interventions carried out by staff, however, there were lots of gaps where these had not always been clearly recorded. One person stated they only wanted care to be provided by female staff; however, male staff had provided care, and this was documented within the person’s personal care charts on several occasions.

Information in people’s care plans was not always accurate, complete and up to date. Staff did not always assess or review people’s needs in a way which gave them clear and up‑to‑date information. Some care plans contained old or conflicting details.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

We found gaps in how the service applied recognised clinical tools such as the Waterlow pressure‑area assessment and the Malnutrition Universal Screening Tool (MUST) nutritional screening tool; these tools are important because they guide staff on what actions are needed to reduce risks such as pressure ulcers or malnutrition.

One person had lost 9 kilograms in weight between the period 22 July 2025 to 7 October 2025, which was the most recent entry in their weight monitoring records. This person’s MUST identified they were ‘dieting toward a normal body mass index (BMI),’ however, the person had already reached the lower end of a healthy weight range at the time of the inspection. The person’s weight assessment had been determined by the provider as high risk, however, the advice for staff associated with this risk which stated, ‘consider recording dietary intake daily/weighing weekly, giving dietary supplements as appropriate,’ had not always been followed. The same person had a daily average fluid intake of half a litre for the period 7 April to 14 April 2026. It was unclear what action had been taken in response to low fluid levels consumed.

We looked at fluid charts for all people living at the home at the time of the inspection, for the period 7 April to 14 April 2026 and found target fluid levels for each person were not always recorded; this is important as fluid target levels vary for each person depending on a number of factors. Older people are also particularly vulnerable to dehydration because thirst sensation is reduced with age and many people relied on staff support or prompting. People’s fluid intake records consistently showed low levels were being consumed.

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

Staff worked with a range of external professionals; however, coordination with these services was not always proactive. Opportunities to jointly review people’s needs, evaluate outcomes or learn from transitions between services were not routinely used to drive improvement.

Staff did not always feel there was effective communication and coordination within their own staff team to enable them to plan and deliver people’s care and support. One staff member told us, “Staff don’thave time to help each other. I can’tget on a break because I’m too busy.”

Our observations of care practice supported this view. For example, the morning medicines round took a long time to complete as the staff member was also carrying other tasks due to staff sickness; this could negatively impact the therapeutic usefulness of some medicines. We also observed a person who remained seated after breakfast until 11.50 a.m. due to there being no staff in the area to help them mobilise safely. We observed one person asking for a drink at approximately 9.15 am and staff told this person to waituntilsnack time at 11am

There was very little of camaraderie between staff, and the perception of cultural differences between staff was affecting staff morale.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

The provider could not demonstrate people were receiving the full level of food and fluid intake expected for those at higher risk, and to sustain a healthy life.There was an increased risk of hospitalisation and avoidable harm.

The provider did not offer opportunities which supported people’s physical and emotional wellbeing. People were not encouraged to take an active part in local community activities, which would help people maintain a healthier and more active lifestyle. Throughout the inspection, was saw many people were slumped in chairs and lacking in motivation.

Feedback from people and relatives regarding the quality of food on offer was overwhelmingly poor. For example, 1 person told us, “I don’t get enough food. Some of the meals are very small. The type of food is not good, it isn’t good quality, they [the provider] provide cheap inexpensive meals. We have had it out with the manager a few times at meetings. We have asked them for fresh fruit and vegetables, and we are getting more now. There is no alternative to a main meal apart from a snack- cheese on toast. Sometimes the meat is poor, and I can’t chew it as the meat is so tough and fatty. Sometimes I feel I haven’t had a good meal. We get too many cakes; it isn’t a balanced diet.’

The registered manager told us the provider had limited the amount of money available to spend on food for each person to £2.50 per day for all meals.

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The provider carried out some monitoring of people’s care and treatment; however, this was not always consistent or effective in driving continuous improvement. We found outcomes for people were not routinely reviewed to ensure they were consistently positive, met relevant clinical expectations, and reflected what mattered to people themselves.

Care records did not always clearly evidence how the impact of care and treatment had been evaluated, particularly when people’s needs changed or risks increased. As a result, opportunities to review effectiveness, learn from outcomes, and make timely improvements were not always taken.

While some outcome information was collected, this was not always used effectively to inform decision‑making or service improvement, therefore the provider could not always assure themselves care and treatment were consistently achieving the intended outcomes for people.

The provider had not fully embedded effective quality monitoring arrangements, and some aspects of governance required improvement.

The provider did not tell people about their rights around consent or respect these whendelivering care and treatment.

The provider had systems in place to support consent to care and treatment; however, these were not always applied consistently in practice. We found people were not always routinely told about their rights around consent, including their right to make choices, ask questions, or change their mind about care and treatment.

Where people may have had difficulty understanding or communicating decisions, the provider did not always clearly evidence how people were supported to be involved as fully as possible, or how decision‑making processes were applied where appropriate. We were not assured consent arrangements were consistently person‑centred and rights‑focused, and the consent section of several peoples care files had been signed by staff.

Where people may have lacked capacity to make specific decisions, the provider did not always clearly evidence appropriate decision‑making processes had been followed in line with the Mental Capacity Act 2005. This meant people could not always be assured care and treatment was being delivered lawfully and in line with their rights. This included restrictions such as the use of bed rails, sensor mats and fluid restrictions for some people. Mental capacity assessments had not been completed regarding these decisions.

People told us information was not always communicated in a clear or timely way. People did not always feel their independence was consistently promoted. We observed many instances where staff supported people in a task focused manner rather than taking time to understand people’s individual preferences.

Some people told us they felt their choices such as preferred routines or activities were not always respected. People were not always involved in decisions about their care, and information in care plans was not consistently accurate or up to date.