Hazelbrook Christian 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

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 good. At this inspection, the rating has changed to 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.

The provider was in breach of the legal regulations relating to premises and equipment.

This service scored 47 (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 have a proactive and positive culture of safety. Staff did not always robustly investigate safety concerns. Lessons were not always learned to continually identify and embed good practice.

Where shortfalls were identified, appropriate actions were not always taken to resolve concerns and promote learning. For example, where concerns were identified through care planning audits, there was no oversight to ensure these were rectified. Where external companies had identified deficiencies regarding the environment, these had not been acted upon and resolved by the provider.

However, there were other occasions where learning was taken from incidents. For example, in relation to falls where actions had been taken and recommendations for any future learning.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Information related to people’s care needs was assessed prior to people joining the service. This helped to inform people’s care plans, risk assessments and the support they needed. One person said, “I came here from hospital as I was very ill. The hospital sent my information over as part of my assessment.”

We saw evidence of the home working well with other health professionals regarding people’s care, for example, district nurses, dieticians and speech and language therapy (SaLT). One person said, “The doctor was here yesterday. In the past I have fallen ill and the home has sent me to the hospital.”

People living at the home and their relatives said they felt safe. One person said, “I feel safe because the staff are very good. They care well, I can’t look after myself to well now and they do everything I need.” A relative also said, “(Person) is safe. The staff are lovely with him and he likes the staff a lot. They take care of him well. He also has a crash mat by his bed for safety reasons.”

The provider did not always work with people to understand what being safe meant to them and to achieve this.

Staff undertook safeguarding training, although the training matrix showed this was last completed in 2024 for some staff, despite it needing to be completed each year. We were told the training matrix was up to date.

Staff told us about instances where poor practice had been identified, but felt appropriate action was not taken to help keep people safe. One member of staff said, “People sometimes have unexplained bruising. Management don’t pay attention.They say it could be because they scratched themselves or something like this.The staff are good,there’s just no time.” Another member of staff said, “Two other staff didn’t use a sling and hoist to move (person) they stood either side of him and pulled him up into the wheelchair.It was reported to management after it happened but don’t know if they did anything about it.” We provided this feedback to the registered manager and provider.

People living at the home and their relatives said they felt safe. One person said, “I feel safe because the staff are very good. They care well, I can’t look after myself to well now and they do everything I need.” A relative also said, “(Person) is safe. The staff are lovely with him and he likes the staff a lot. They take care of him well. He also has a crash mat by his bed for safety reasons.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In[care homes/hospitals], this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS),which is part of the Mental Capacity Act 2005(MCA).We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found DoLS applications were made to the local authority as required and renewed when they expired.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People had risk assessments in their care plans, although these did not always provide sufficient details about how to keep people safe. For example, where people used pressure relieving mattresses, this was not clearly documented in their care plan and the settings they needed to be maintained at.

Not all risk assessments were in place for areas including bed rails, choking and moving/handling. This meant staff may not always have sufficient information available to keep people safe.

People living at the home and relatives told us they felt risks were mitigated. One relative said, “(Person) has had a couple of falls but nothing serious. They have called me. They didn’t need to call the doctor out.” Another relative added, “(Person) has cream for their skin, but I am not aware of any pressure sores. (Person) has cushions around their ankles to relieve pressure.”

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

An up-to-date fire risk assessment had not been completed and actions required from the previous version in 2025 had not been resolved. This included gaps under bedroom doors which could allow smoke into the room. Bedroom doors were also being held open by inappropriate means which would prevent them from closing properly.

Not all bedroom doors in the home were fitted with self-closing devices to allow the door to close in the event of a fire. We made a referral to Greater Manchester Fire and Rescue Service following our inspection and they planned to carry out a visit to the home.

Parts of the environment were not well maintained and there was no on-going home improvement plan in place to identify these issues and show when they would be rectified by. Areas of the home not appropriately maintained included rotten window frames of several upper floor bedrooms, the front door, damaged/chipped paintwork on doorways and handrails throughout the home, damaged/cracked ceilings in the corridors and damp patches on ceilings.

The last electrical installation report was carried out on 6 August 2025, however several faults were identified which needed to be addressed. This included inappropriate light fittings and several damaged sockets. These had not been repaired at the time of the inspection.

The provider did not always make sure there were enough qualified, skilled and experiencedstaff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The feedback we received from people and relatives was that staffing levels were not sufficient. One person said, “No there are not enough staff. When I first came here last year there were more staff then. Recently in the last few months the staff have reduced in numbers.”

Staff also raised concerns with us about staffing levels and felt agency staff didn’t always receive the necessary training for the role. A member of staff also said, “Not enough at all.33people andI’mthe only onesometimes doing anything.Someone passed away so they cuta member of staff from the allocation.”

We carried out observations during the inspection to see if there were enough staff to care for people safely. Whilst there were four care staff and a nurse on duty during the day, the main lounge area and dining area where people were seated was left unobserved for periods during the day. During this time, we heard people asking to be taken to the toilet. When staff came back into the room, there had already been a delay.

Staff said online training took place and a training matrix was in place where completed courses were recorded. These included safeguarding, data protection, mental capacity act (MCA), deprivation of liberty safeguards, equality and diversity and fire safety.

Staff were recruited safely, with appropriate pre-employment checks carried out before staff started working with the service which included Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Staff had opportunities to learn, and any poor performance was managed appropriately.

The provider had not always assessed and managed the risk of infection. The provider detected and controlled some risks and understood they needed to communicate concerns with appropriate agencies promptly.

There was a lack of effective maintenance of the premises which increased the risk of the spread of infection. Some skirting boards, door frames and doors were not maintained and were in need of repair. This made it difficult to keep clean and minimise cross infection risks.

The home had received a recent food hygiene inspection and a score of 2 had been awarded which was downgraded from a 4 previously, where concerns were identified regarding practices in the kitchen.The home were currently waiting for a re-inspection from the local authority to improve the score.

We saw some positive practices to minimise cross infection. Handwashing signage was displayed in some toilets, bathroom areas and personal protective equipment (PPE) stations were available throughout the home. Staff were seen to use the appropriate PPE at the required times.

The provider did not make sure that medicines and treatments were safe and met people’sneeds, capacities and preferences. People were not involved in planning.

Medicines were stored securely and managed by staff who had been trained. Although there was evidence of some competency checks for staff administering medicines, this wasn’t always done for areas such as choking and the use of drink thickeners.

Although staff monitored the temperature of areas used for storing medicines when records showed that the fridge had been out of the recommended temperature range, staff had not always acted. We could not be assured that medicines had always been stored safely.

Protocols for PRN (when required) medicines were available to staff; however, they did not always contain person centred information that would ensure staff could give these appropriately. For example, for one person who had a medicine prescribed to manage agitation there was no instructions for staff to indicate how they could support this person to avoid the escalation of symptoms so the medicine wouldn’t be needed. Staff did not always record the reason why PRN medicines were prescribed or the outcome of their use. There was not always documentation made around incidents that led to the administration of medicines for agitation. This meant that we could not be assured that people weren’t having their behaviour controlled by medicine.

Medication administration records (MARs) did not always reflect that people received their medicines as prescribed. We saw gaps in MAR charts where staff had not signed for medicines administration and staff did not always document the time Parkinson’s medicines had been administered. For one person who had a patch applied daily that required it to be applied to a different site each day for 14 days, staff did not always document the location of the application of the patch and when it had been recorded staff had not always followed the instructions on rotation of the application site. We could not be assured that people always received their medicines as prescribed.

For one person who received their medicines covertly (hidden in food and drink) staff had completed a capacity assessment and related paperwork however this lacked information on who had been involved in the decision. There was information from a healthcare professional on how to administer the medicines safely in this way however this information wasn’t available for all the persons prescribed medicines.