Hatzfeld 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. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 78 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Incident investigations were detailed and analysed by the management team and outcomes were communicated to staff to ensure lessons were learnt. Staff identified through incident analysis that one person was experiencing emotional distress mainly in the evenings. Measures were put in place to provide one-to-one support, and care plans were reviewed with a safety support plan added. These actions helped reduce the person’s distress and led to a positive outcome. The provider considered duty of candour and followed as appropriate.

The provider worked with people and healthcare partners to establish and maintain safe systems of care; this was safely managed and monitored. The provider ensured there was continuity of care, including when people moved between different services. Comprehensive pre-admission assessments were in place including assessments from other healthcare professionals involved in people’s care, where relevant, such as social workers and the community mental health team. There were close working relationships with partners to maintain continuity of safe care and safety during transitions. Referrals to healthcare professionals were made in a timely way.

People were protected from abuse, neglect, and discrimination. Safeguarding policies were in place and staff had completed safeguarding training. Staff understood the principles of safeguarding and were confident in how to report abuse in the service. One staff member told us, “I would report to management straight away and CQC if needed, but I am absolutely confident that management would deal with it.” People told us they felt safe living at Hatzfeld House, one person told us, “I do feel safe here and I can talk to everyone.”

Relatives told us people were safe and well looked after, comments included, “[Person] is safe and happy there, I cannot fault the staff, and I know that [person] is safe and being well looked after.”

Safeguarding referrals were made to the local authority where required and CQC were notified appropriately. 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 appropriate processes and procedures had been followed to ensure people were not unlawfully deprived of their liberty.

The provider demonstrated exceptional commitment to person-centred care and holistic risk management. People were fully involved in understanding and managing risks, ensuring care was delivered in a way that was not only safe but empowering and meaningful. Care plans and risk assessments were robust and contained highly detailed personalised guidance that enabled staff to support people confidently and consistently. Healthcare needs were addressed proactively, with comprehensive plans covering areas such as women’s health screening and pain management.

Positive risk-taking was actively encouraged, reflecting a culture that prioritised choice and control. People were encouraged and supported to do their own laundry and light cleaning where able to, which instilled a culture of promoting people’s autonomy and choice. People were actively involved in planning tasks and activities during monthly residents’ committee meetings, where staff worked collaboratively with them to assess and manage any associated risks. This inclusive approach promoted independence and autonomy while ensuring safety. For example, people and staff jointly formed the ‘Hatzfeld Hammers’ football team, agreeing on risk measures together before competing with other local homes, demonstrating empowerment, shared responsibility, and person-centred decision-making. Lunchtime arrangements enabled people to select their own meals, with staff offering proactive, discreet assistance to those who required it. This approach fostered independence and enhanced wellbeing. Staff were skilled to understand and recognise risk and positive risk taking was promoted within the service. We observed at lunchtime, people walked up to a hatch to choose their meal options and staff proactively supported those who were unable to.

Staff were highly skilled and knowledgeable, underpinned by exceptional training programmes that focused on individualised risk management. Policies were not only in place but embedded in practice, such as the Falls Management Policy incorporating the innovative ‘REACT’ toolkit to reduce falls and promote best practice. This demonstrated a strong commitment to continuous improvement and innovation.

The environment was well maintained. Systems were in place to maintain a safe environment with a range of maintenance audits completed. Appropriate arrangements were in place to manage emergencies. Equipment was monitored and serviced with regular audits carried out by maintenance staff and the registered manager. Fire safety checks and comprehensive audits were carried out to ensure people knew how to respond in the event of a fire. People had personal emergency evacuation plans which were visible in people’s rooms, these plans were updated monthly to ensure staff and emergency services had up to date information on how to evacuate people safely.

There were enough skilled and experienced staff to meet people’s needs and staff received effective support, supervision and development to provide safe care. Comments from staff included, “I struggle with training sometimes, but they have supported and encouraged me to get it done. Whatever I needed help on, they were there to straight away.” and “They have been fantastic with me and supported me to through everything, I’ve done all my training now and now doing medication training.”

Staff told us they felt there was enough staff to carry out their roles. We observed staff responding to people in a timely manner.Relatives told us there were enough staff to support people’s needs, one relative said, “Yes, I always see staff when I visit.Recruitment checks were appropriately carried out by the service. Supervisions and appraisals were completed by the registered manager to provide effective support and guidance.

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 the home to be clean and tidy, and staff adhered to good infection prevention and control (IPC) practices. For example, we saw staff wash their hands and use appropriate personal protective equipment before supporting people during mealtimes.

People and their relatives told us the home was clean, people’s rooms were kept clean, and the Home was well maintained. Systems were in place to maintain and monitor cleanliness including cleaning schedules and a wide range of IPC audits.

Medicines were managed safely and effectively. People were given their medicines and treatments at the right time using a person-centred approach. Systems were in place to ensure medicines, including controlled drugs were stored safely, and fridge and room temperature checks were completed appropriately. Staff received training and their competency was assessed. Staf knew people well and this helped to reduce the use of medicines to manage people’s distress. For example, one person prior to moving to the service required medicines to support their behaviour and since settling into Hatzfeld House, medicines to support this was no longer required. Instead, staff focused on meaningful interaction and engagement to foster inclusion and belonging; this considerably reduced the person’s distress. PRN protocols were in place to support staff to administer ‘when required’ medicines. Staff administered medicines in line with best practice guidance.