Hazelbrook Christian Nursing Home

On this page

• 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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of the legal regulations relating to good governance.

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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Staff told us they did not always feel involved in shaping the direction of the service or understand how their role contributed to the provider’s wider aims. There was limited evidence of a shared vision based on transparency, equity, equality, human rights, diversity and inclusion. As a result, staff engagement with the provider’s values was inconsistent, and this affected how confident staff felt in raising concerns or contributing ideas for improvement.

Several staff expressed concerns about the use of CCTV within the service. Staff told us the monitoring arrangements felt punitive rather than supportive, and they did not always understand how CCTV was used proportionately to balance people’s safety with staff trust and well‑being. This perception had a negative impact on staff morale and did not support a culture of openness, learning or psychological safety. Leaders had not always communicated clearly how surveillance systems aligned with the provider’s values, nor how staff rights and dignity were protected.

A lack of clear strategic direction and inconsistent engagement from leaders meant the culture was variable across the service. This reduced opportunities for shared learning and continuous improvement and did not fully support the delivery of person‑centred care. People told us the registered manager was not always visible within the home. One person told us, “I don’t know the manager, she hasn’t been in to see me.” A second person said, “The manager tends to stay in her office.”

The registered manager recognised further work was needed to develop a more open, inclusive and values‑driven culture. However, at the time of inspection, improvements were not sufficiently embedded to demonstrate a consistently positive shared direction and culture across the service.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Leaders were not always able to demonstrate they were consistently capable, compassionate and inclusive. While some leaders were visible within the service, there were gaps in leadership effectiveness limiting their ability to drive improvement and provide clear, values‑led direction.

The provider did not always embody the culture and values they expected from the workforce. Staff feedback indicated leadership behaviours were inconsistent, and this did not always promote openness, trust or shared ownership. Some staff told us leadership actions did not always reflect compassion, inclusion or a commitment to equality and human rights.

Staff confidence in leadership was limited and did not support a positive learning culture. A staff member told us, “The sponsored staff, are very cliquey and won’t help and a lot of them are friends with the deputy manager so you have to be careful what you do or say to them because it’ll go back and you’ll be targeted.” Leadership arrangements were not effective in supporting continuous learning, improvement and inclusive practice across the service. We saw the provider operated an ‘employee of the month’ scheme.

People did not always feel they could speak up and that their voice would be heard.

The provider did not foster a positive culture where people felt they could speak up and their voice would be heard. A staff member told us, “I usually don’t speak up because of the sponsorship. The current manager is very good, but I have mixed feelings about the deputy manager; when he is on duty he is very rude to me. Because he is close to owners, the manager is neutral.”

Learning from previous complaints had not been fully embedded into practice. Shift handover records contained limited detail. Several people stated improvements need to be made and told us they were unaware of the registered manager. A person told us about the poor quality food with very small portions and not enough fruit and vegetables. They also said, “Personal belongings have gone missing, and management didn’t want to take responsibility; the belongings have never been found.” We were informed by the registered manager that these items had since been replaced.

Staff did not feel their wellbeing was supported and had different opinions on whether or not they would be listened to. One staff member told us, “Staff are monitored constantly by CCTV, even duringbreaks,there’sa camera outside where people go for a cigarette or to eat.” A second staff member said, “The owners [provider] will not change to help us. They don’t give enough pads to use, nursing people are paying for pads, but we are told to use thin pads for everyone. We are told we have 2 pads for each nursing client all day. The deputy manager said, “Pads have capacity for 8 hours of use; if it’s wet its fine- that’s what it’s meant for, if it’s got faeces just wipe it off.”

The staff handbook had last been reviewed in August 2023 and contained the name of the previous registered manager. The service user guide had no information regarding the use of CCTV and no date; it also identified another different registered manager name.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff feedback regarding the culture within the home indicated some staff felt they were not treated equally. One staff member told us, “It’s very much like the white staff versus the other staff. They [non-white staff] keep themselves to themselves; they all talk in their own language. If I’ve ever asked for help from those staff they just shrug their shoulders. The nurses can be abrupt with residents.”

Consistent leadership was required to ensure a sustained positive culture within the home. Staff did not always work well together. A staff member said, “The white staff will be pulled up on the little things constantly, but they [leaders] never pull the other [non white] staff up on anything; even the same thing that they’ve pulled others up for.”

Staff were representative of the population of people being supported and had access to equality training to help them understand about protected characteristics, bullying and harassment.

The provider did not have clear responsibilities, roles, systems of accountability and goodgovernance. They did not act on the best information about risk, performance and outcomes, orshare this securely with others when appropriate.

The provider did not have robust governance systems in place to monitor the quality of service provided, which covered areas of concern found at this inspection. For example, the environment, person centred care, seeking consent and fire safety. There was no oversight to ensure actions from the registered managers care plan audits were implemented. The was no on-going home improvement plan where any environmental deficiencies could be monitored and improved.

The registered manager told us the provider visited them every week. However, it was unclear what activity the provider routinely undertook to monitor the quality and safety of care, treatment and support and there was no evidence of any provider audits being carried out, aside from medication. We saw examples of provider emails to the registered manager questioning issues raised to them.

In one example was saw a provider email to the registered manager regarding staff concerns about CCTV monitoring stated the CCTV was only installed the car park, however, the CCTV screen in the registered managers office covered many areas of the home. Staff confidence in the provider was limited, one staff member said, “I know that the owner [provider] consistently monitors us directly; she rings the home and knows exactly where staff are at certain times.”

Staff meetings took place every month and a schedule of meetings was in place. However, staff had mixed views on the usefulness of these meetings in supporting them to carry out their roles effectively. One staff member told us, “Staff meetings are every month; wedidn’tused to have these and it’swhat [registered manager name] has started.It’sthe same thing every time; reminders about repositioning andstaff not speaking in English in front of residents.” A second staff member said, “Staff meetings are every month; we don’t speak much, it’s mostly same things about repositioning and breakfast on time and if family have complained.”

The provider had a business continuity plan, which covered the relevant areas, in the event of an unforeseen emergency. However, this plan was produced by a UK‑based company who provide policy, guidance, audit, learning and care‑management systems for health and social care providers, with accountability always remaining with the registered provider and registered manager. The business continuity plan did not always identify if the suggested control measures had actually been implemented.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Information and learning were not always shared in a timely way, and opportunities to support continuity of care, manage risks collaboratively or improve outcomes for people were sometimes missed. Clear systems and guidance were not always in place to support consistent practice across the service. As a result, effective partnership working was dependent on individual staff knowledge rather than embedded organisational processes.

The home had some established links with external agencies; however, these relationships were not always used proactively to support service improvement. There was limited evidence learning from incidents, complaints or quality monitoring activity was routinely shared with partner organisations to support joined‑up learning or collective improvement.

The provider needed to strengthen their approach to partnership and community working by putting into place clear arrangements for routine communication, information sharing and joint learning with partner agencies.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider’s auditing systems were not always robust. The registered manager completed range of checks and audits to monitor the quality and safety of the service and to help drive improvements. However, although auditing systems had identified some of the issues we found during this inspection, they had not resolved them.

Systems to review and learn from care records and documentation were not always effective. The provider had not resolved the issues regarding staff not consistently keeping accurate, contemporaneous records of people’s care and support, and as a result the providers’ ability to learn from staff practice, monitor quality or implement improvements based on reliable information, was limited in success. Although care planning audits by the registered manager had identified some of the issues found during this inspection, they had not been actioned within identified time period.

We were not assured leaders had a good understanding of how to make improvements happen. We were not assured there was a robust process for sharing learning from incidents and accidents and complaints.