Hazelwood House

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. We rated this key question Good. This meant people were safe and protected from avoidable harm. The service provided care and treatment in a way which made patients feel safe, supported, involved and listened to. Patients felt they were respected and treated with kindness, and compassion. They were treated as individuals and encouraged to be involved in their care and treatment planning. Staffing, processes, and equipment were in place to maintain the safety of the patients and to meet their needs. Staff engaged with patients in a kind, compassionate, and caring way. The environment, and equipment was clean, tidy, and well maintained. Information regarding the patient's care, treatment, and external resources available were displayed throughout the service.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service ensured that learning from incidents was identified, shared with staff, and used to improve care. When incidents such as episodes of agitation or aggression occurred, staff responded quickly, reported them appropriately, and updated care plans and risk management plans accurately. Following incidents, patients and staff had debrief meetings, the psychology team also facilitated individual or group reflective practice sessions and were also available on an ad hoc basis if required. Staff demonstrated a strong understanding of the duty of candour. If things went wrong, they spoke openly and honestly with patients and families, offered clear explanations, and apologised whenever needed. The service had 5 Freedom To Speak Up (FTSU) champions who were also available to support staff if required.

Managers and clinical leads provided staff with regular feedback following investigations. One staff member told us “Communication after incidents is very good, any lessons we learn are always shared through numerous meetings, and electronically for staff who can’t attend.” Teams discussed learning during daily morning meetings, handovers, regular team meetings, and monthly operational meetings to identify areas for improvement. Staff used feedback, both positive and negative as learning opportunities to improve upon practice, and service delivery.

Patients felt well-supported and reassured during referral, admission, transfer, and discharge processes, which helped reduce anxiety during times of transition. They had information about what to expect from their care and treatment available to them in a variety of formats to suit individual needs.

Staff and leaders explained that the service had robust systems in place to ensure safe admissions, care transfers, and discharge planning. They reviewed referral documentation carefully, including clinical history, risk assessments, and care plans.

Upon receipt of a referral the service arranged a face-to-face assessment with the referred patient. Depending on the needs of the patient, a specialist Nurse was always part of the assessing team, for example, a learning disability or mental health nurse. Staff said this process ensured the patient was appropriate for their service, and they could safely meet each patient’s needs.

Leaders promoted the importance of early planning and communication across teams. Discharge planning involved coordination between services, for example, the Assertive Transitions Service (ATS) to ensure safe and supported transitions, and ongoing care and support. Staff made every effort to avoid unnecessary delays and remained focused on achieving timely discharges wherever possible.

The service followed a structured process where staff completed comprehensive admission protocols when a patient was admitted, the process involved the patient as much as possible and was reviewed regularly, any follow up information was used to support safe and timely care planning, and effective assessment of risk.

Patients consistently felt safe and empowered to raise concerns, knowing staff would support them appropriately, if they felt unsafe or had any concerns about others. The service promoted and supported patients to be patient safety leads, who were empowered to share their views on all aspects of safety within the service. Patients were included, and their voices heard.

Staff demonstrated a thorough understanding of safeguarding, confidently identifying and responding to concerns to protect patients from harm. They took appropriate and timely action to protect patients from abuse, neglect, or discrimination and worked collaboratively with external agencies when required, for example, the local authority social safeguarding team. Staff discussed safeguarding incidents in daily morning meetings, safeguarding meetings, multidisciplinary team meetings (MDT), and safety huddle meetings. Staff were also supported by safeguarding leads based at the service. Staff demonstrated a clear understanding of Deprivation of Liberty Safeguards (DoLS). Staff explained patients’ rights to them, including their rights under the Mental Health Act 1983, Mental Capacity Act 2005, and the Equality Act 2010.

Leaders ensured staff had the knowledge, support, and confidence to act accordingly and promptly to safeguard the patients they cared for and supported. One staff member told us “You should always consider the right way to support the patient, and in a way that they understand. Always considering individual vulnerabilities, and sexual safety.”

The service had effective safeguarding systems, policies, and procedures in place that upheld patients' human rights and promoted a culture of safety. We reviewed the safeguarding incidents log for the period from June 2025 to August 2025 and found that concerns had been thoroughly investigated, escalated to the appropriate agencies in a timely manner, and outcomes and learning shared.

Staff knew and understood patients’ individual risks, which ensured they intervened and responded quickly to support patients to minimise any distress and to decrease risk.

We reviewed 7 risk management plans and found they were person-centred with obvious patient and family involvement and were reviewed in line with organisational policy. One patient told us “I feel really involved; my family are also included. I go through my care plan with my Nurse, and we always talk about it in MDT meetings.” Staff took a proportionate, and balanced approach to risk, welfare checks and observations were completed in line with the patients’ care plan and based on individual patient need. The patient records we reviewed showed observations were completed as prescribed.

Staff ensured patients' physical and emotional needs were managed positively, protecting their rights and their dignity. Staff had a calm approach when supporting patients with any episodes of distress, which promoted safety and mitigated any further potential risk and escalation.

Staff involved patients and supported their families in formulating risk assessments. In the care records we reviewed, we found evidence that Patients and their families fully participated in MDT meeting reviews. Families who could not attend MDT meetings in person were supported to attend virtually, for example, Microsoft Teams. Staff from various teams within the service supported patients to understand their risks and how to manage them positively, for example, the Psychology team. Numerous communication methods were used for patients with identified language barriers or other complex needs, for example, easy read print, and picture-based emoji documentation. Restraint was used as a last resort. It was documented accurately, proportionate and in line with best practice. Care and treatment plans reflected any restrictions and were based on the patients’ individual risks to avoid blanket restrictions.

The service had completed a patient led project around reducing restrictive interventions. The project looked at the effects of physical interventions from the perspective of the patient and the potential effects. The physical intervention rates had fallen, and the service had received positive feedback from both patients, and staff.

Staff considered the importance of equality and human rights legislation when imposing any restrictions. If rapid tranquilisation was used, it was also proportionate, documented appropriately and recorded in line with best practice.

Patients and staff felt the environment was safe. The service effectively maintained clean, and well-equipped environments that promoted the physical, and mental wellbeing of the patient and supported the safe delivery of care. Equipment was well-maintained, stored safely, and used appropriately for its intended purpose.

A security nurse completed safety audits of the environment on every shift and fed back the outcome at the shift handover meeting. The security nurse was a member off staff delegated with the task of checking the safety of the environment on a shift-to-shift basis to ensure there were no unidentified risks. The service had a fire safety lead who also checked the environment on a shift-to-shift basis to ensure all fire safety and evacuation protocols could be met in the event of an emergency. One staff member told us “The security Nurse checks absolutely everything, both inside the building, and outside. We understand how important is to keep everyone safe.”

The ward staff teams completed regular risk assessments of the environment throughout the day and night. Environmental audit consistency ensured any potential hazards were identified and required actions taken to mitigate any risks. Ligature risks were assessed, and the appropriate assessments were in place to manage and reduce any potential risks of harm. The service had CCTV throughout, this supported and safeguarded both patients and staff against the potential risk of blind spots.

Staff carried personal alarms and radio communication systems. Patients had access to nurse call systems in their bedrooms, bathrooms and throughout the environment. This ensured they could request assistance or support whenever needed.

The clinic room was fully equipped with accessible resuscitation equipment and emergency medicines; staff checked and audited these regularly to ensure preparedness for any potential emergency situations. There was also a back-up emergency equipment bag which was stored in an alternative accessible location.

There was a well maintained and secure outdoor space which was well used by patients. The doors to the outdoor space remained unlocked and allowed patients, to access the area freely. The appropriate security measures were in place throughout the outdoor space, which ensured that people were safe when using it.

Equipment, and technology were well-maintained and ensured staff delivered safe and effective care. The service had effective processes to monitor the safety and upkeep of the environment, and premises.

The service and its staff knew what was required to provide and maintain environments that kept people safe from physical and psychological harm including attention to sexual safety and sensory needs.

Patients were well supported, staff were always present, visible, and available. One family member told us “I know my son is well cared for at Hazelwood House. He’s safe there, and that makes me feel happy and reassured.” Patients were supported to have regular one-to-one time with their named nurse which we found evidence of in the care records we reviewed. This maintained therapeutic relationships and promoted continuity of care.

Staff were present in communal areas, and throughout the environment. The appropriate medical cover was in place throughout the day and night, with doctors and an on- call pharmacists being readily available to respond quickly in cases of emergency.

Leaders regularly reviewed staffing levels and aligned them to the needs of the service, and the patients it supported. We saw evidence of how staffing levels were increased when patients’ needs changed. Staffing rotas confirmed the required numbers, and the appropriate skill mix was met on the vast majority of shifts. Any gaps identified in staffing had been covered in a timely and effective way to maintain the service provision.

The service utilised agency staff to complement the existing workforce when required. Agency staff completed an organisational induction and mandatory training prior to employment and were regular to the service; they were familiar with the patients and environment. Agency staff also completed observational competencies prior to commencing work, this ensured the correct processes were adhered to and enhanced the safety of the patients being supported by the service. One staff member told us “The agency staff are regular to the ward, there really good and really valued. They know the ward well and have good relationships with the patients.”

We reviewed vacancies, staff turnover and sickness absence levels in the past 12 months and found no concerns. The service did have staff vacancies, and they were recruiting into these roles at the time of our visit.

Recruitment processes were robust and ensured that all staff, including bank staff, had current Disclosure and Barring Service (DBS) documentation in place, were suitably qualified, experienced, and competent. Disciplinary and capability processes were adhered to, reviewed regularly, proportionate, and free from bias related to protected characteristics.

Staff felt supported by leaders, and had monthly clinical, and managerial supervision. All staff also had yearly appraisals, and personal development reviews (PDR). We reviewed supervision, and appraisal documentation, and found it met, and often exceeded the organisations compliance target. Staff had completed and were up to date with role specific mandatory training, with a current compliance rate of 94.1%. The training undertaken was appropriate for the patient group being supported. Staff demonstrated confidence and competence in care delivery. Opportunities for learning and development were available to staff at all levels. Any poor performance was managed promptly, and effectively.

Patients were confident in the infection prevention and control (IPC) processes in place and felt assured that staff were taking necessary precautions to protect them from the risk of infection and potential harm. One patient told us “The place is always clean; we have cleaners and staff also clean up and keep things nice through the evening and night.”

Staff adhered to infection prevention and control procedures, followed handwashing guidance, used personal protective equipment (PPE) appropriately, and cleaned equipment in line with guidance, and best practice.

We observed staff barrier nursing a patient and adhering to IPC principles, and guidance between patient interventions, for example, hand hygiene, changing personal protective equipment (PPE), and correctly disposing of waste items. Barrier nursing is the practice of caring for the patient in their own room or area due to illness, infection, and the potential vulnerabilities of other patients.

All ward areas were clean and well-maintained. Cleaning records were up to date and showed that areas were cleaned, and audited regularly, this ensured the environment was hygienic and safe. Staff demonstrated a good understanding of their roles in maintaining the cleanliness of the environment. Hand sanitising stations were situated throughout the service; this protected people and mitigated the risk of infection and potential harm.

The service had clear processes in place for assessing and managing infection risks. The providers’ procedures aligned with current national guidance. Cleaning and IPC audits were completed regularly, with all concerns addressed promptly. Information about infection risks was shared appropriately with staff, patients, visitors to the service and external partners. There were clearly defined roles and responsibilities for IPC, and staff received ongoing training in line with organisational policy, and best practice guidance.

Staff supported patients to be involved in decisions about their medicines. For those who had capacity, staff ensured they understood what their medicines were for and involved them in any discussions regarding changes to their treatment. Where patients lacked capacity, and were not able to fully understand or participate, due to diagnosis related impairment, staff adhered to processes in line with the Mental Capacity Act 2005 and the Mental Health Act 1983. Care plans we reviewed reflected each person's level of understanding and evidenced the level of involvement they had in making decisions about their medicines and treatment.

Staff followed safe and effective practices in all areas of medicines management, including storage, dispensing, administration, reconciliation, recording, and disposal. The service adhered to national guidance and best practice, and evidenced how they involved patients, their families, and people who knew them well in discussions and decisions about their care and treatment wherever possible. Staff regularly reviewed the effects of medicines on patients’ physical health, particularly in those prescribed a high dose of antipsychotic medication, in line with NICE guidance.

We observed staff administering medicines safely, explaining their use clearly, and supporting patients with kindness, and compassion. The service stored medicines securely, including controlled drugs. All medicines were managed under the required legal frameworks. Fridge and room temperatures were checked daily, and all medications were within date. Expired or unused medicines were disposed of safely. Staff ensured that medicines were used appropriately. were Pro Re Nata (PRN) or when required medicines were used, we found they had been used appropriately and not purely to control behaviour. The service administered medicines in line with Stopping Over-medication of People with a learning disability, autism, or both (STOMP). We reviewed all prescribing, and administration records and found no concerns.

The service had robust and effective systems in place for the management of medicines and adhered to current best practice, prescribing followed national guidance. When staff identified medicines errors, they were addressed and the appropriate actions taken to mitigate the risk of harm, or reoccurrence. Continuity of care was maintained during transitions between care settings through effective medicines reconciliation and clear concise documentation. Controlled drugs were managed safely and audited regularly, and any outcomes from audits were acted on. This promoted a learning culture through incident reporting and review. Staff had received training and competency assessments to support the safe, effective, and appropriate use of medicines.