Hazel Garth

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
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 assessment 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.

This service scored 53 (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 based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The registered manager maintained a log of incidents to aid monitoring and analysis for themes, and this was being further developed to record the actions needed and to monitor the progress of each action. The manager told us that lessons learnt from incidents were discussed with staff in staff meetings, however staff could not consistently explain lessons learned from incidents or describe how changes had reduced risks for people.

Safeguarding measures to prevent incidents were not consistently identified and action to prevent reoccurrence had not always been taken. This limited the provider's ability to identify trends and make improvements. Despite these findings, some relatives felt the service responded positively when concerns were raised.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

People’s needs were reviewed by managers before people moved into Hazel Garth to ensure people’s needs could be supported. Some assessment information was provided by other professionals and managers did not always see people face to face before they arrived at Hazel Garth, for example when people were being discharged from hospital. In these instances, managers reviewed the information provided from other professionals to ensure relevant equipment was in place before the person arrived to ensure safe care.

However, staff told us they did not always have time to read care plans or risk assessments following a person’s admission and “some things are getting missed.” This meant staff lacked clear, detailed guidance to enable them to support people safely.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.
There were delays in reporting safeguarding concerns to external partners and therefore we could not be fully assured staff consistently recognised when poor practice, neglect or unsafe care placed people at risk of harm.
Staff had completed safeguarding training and demonstrated an understanding of safeguarding processes and how concerns should be reported. Staff told inspectors they would raise concerns with management and escalate concerns if appropriate action was not taken.
People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, 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 that the registered manager kept a record of DoLS applications and authorisations and appropriate MCA assessments were in place.

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’s risk assessments had not always been reviewed or updated to accurately reflect their needs. For example, 1 risk assessment had not been reviewed since November 2025 and where risks had been identified and required ongoing monitoring, no information was being recorded in care records. This placed people at risk of harm.
However, people felt safe living at Hazel Garth. They told us, “I am happy here, I am safe,” and “I don’t feel unsafe here.” Relatives expressed mixed views. Feedback included, “Yes, I think [person] is safe here,” and “Yes, I think [person] is safe here, but I am not sure, there are a few things I am not sure about.”

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

There was no signage around the home to guide people to their rooms or bathrooms. This meant that for people living with dementia they could not easily identify where they needed to go or recognise their room. We observed some people going in and out of different bedrooms.
The fire risk assessment had recently been completed and whilst the home was compliant, there were 3 areas identified as needing review, 2 of these had been identified in previous reports and whilst these were not mandatory requirements, they had not been addressed in line with best practice.
The environment was clean and in good state of repair. Environmental checks had been completed, and certificates were up to date. Personal Emergency Evacuation Plans (PEEPs) were in place, up to date and could be easily accessed in an emergency. Maintenance and other safety checks were in place.

The provider did not always make sure there were enough qualified, skilled and experienced staff. 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.
There were not always enough staff to meet people’s needs. Despite the use of a dependency tool there were several times during the day where the service was understaffed.” In addition, we observed a person asking a member of staff to help them outside and was told they were on their own and would help when another staff member came.
We raised this during our on-site visit with the management team and was told that staffing balanced out through the day as “not everyone needs personal care at the same time.”
Staff consistently told us that there was not enough staff. Comments included, “Staffing levels can vary but if we have 4 staff on, it is enough but if we have agency staff on, it is not enough. I remember a shift with 2 agency and a new starter. They were shadowing and it was the most stressful shift of my life,” and “Not enough staff, I know we have agency staff coming in at the minute. On one shift there was a new person who had not been trained and 2 agency workers. I was the only person to run the shift and support 20 people to get out of bed.” Another staff member told us, “For [person] there is not the staff to take them for breaks outside.”
People and relatives were not always sure they were enough staff, comments included “I think they can be short of staff, they do have agency staff, but they don’t know people as well.”
We raised this with the management team during our assessment, and they were acting to remedy staffing levels.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We observed staff wearing appropriate PPE and they demonstrated good practice with hand hygiene. A cleaning schedule was in place, and regular audits were completed to ensure compliance, however during our visit some areas of the home had an odorous smell. In addition, some staff needed to complete IPC training. This was scheduled to take place over the following six weeks.
Managers completed regular infection prevention control audits. These included audits of the environment, equipment, and staff spot checks.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff were not always following the providers processes and records were sometimes lacking detail or contained inconsistencies that could impact on people’s care.
Medicines were not always managed safely.
Medicines were stored securely. The medicines trolley was locked and anchored when not in use. Controlled drugs (CDs) were stored and checked using additional records, and staff were completing regular balance checks. However, staff did not always follow the providers process for administering controlled drugs which stated 2 members of staff should sign out a medicine and observe the administration. During the inspection we observed staff not following this process. This was discussed with the registered manager.
There were systems in place to support people with “as required” (PRN) medicines. Some PRN records included person-centred information about how people may show pain or breathlessness, and staff recorded effectiveness for some medicines. However, PRN protocols were not always detailed enough. They did not always include information about when staff should escalate concerns, what non-medicine approaches should be tried first, or whether the medicine had been effective when it was given. Strengthening these records would support staff to make consistent decisions and reduce the risk of medicines being used without clear rationale.
Where medicines were administered covertly (hidden in food or drink), the service had involved relevant professionals and family members. However, records did not always clearly show review dates or whether staff had first offered medicines openly before giving them covertly. Improving this would help the service evidence that covert administration remained the least restrictive option.
There were some inconsistencies between records, including allergy information not always in line with care plans and MARs, and some records having conflicting information about whether they could be crushed. Patch rotation charts were not always available for prescribed patches, including a controlled drug patch. These issues meant the service could not always fully evidence that medicines were administered, reviewed and monitored as safely as possible.