Hazel Villa

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

We looked at all quality statements for Safe at this assessment. The service was safe.

People were protected from bullying, harassment, avoidable harm and abuse. Systems were in place to keep people safe. Risks to individuals were managed well so that people were protected, and their freedom was supported and respected. There were enough suitable staff with the right competencies, knowledge, and attitude they needed to keep people safe, meet their needs and promote their rights. Staffing levels were based on the type and level of support each person needed throughout the day and staff were deployed in a way that was consistent with person centred care which included going out and planned activities. Staff received support and development to enable them to meet people’s needs and poor performance was addressed. The management of medicines was safe and good infection control practice was being followed. Transitions in care pathways were managed well and staff worked effectively with other health professionals and services to optimise support and continuity for people.

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.

People felt safe to raise any concerns they may have and had confidence they would be treated positively with understanding and compassion.

Leaders told us that safety at the service was a priority. The provider and management had created a positive learning culture where they encouraged and supported people and staff to raise concerns through various forums. Staff told us leaders and management were open and transparent, and they listened and acted on any concerns.

There were processes in place to proactively find, manage and control risks before safety events occurred. Where incidents or safety events had occurred, they were thoroughly investigated. Lessons were learned from safety events and shared with staff resulting in changes to improve practice, improve care and prevent re-occurrence.

Safety and continuity of care was a priority throughout people’s care journey.

The service was pro-active in planning and organising continued care and support for individuals following admission to Hazel Villa. For example, the service was working closely with the community mental health team in relation to a person whose mental health needs were fluctuating daily during transition from acute care. This was being closely checked and care and support plans were regularly reviewed and revised to ensure their needs were being met and risks were managed and reduced.

Professionals gave positive feedback about the service's positive joined up approach that ensured safety and continuity of care for people.

One professional said, “Staff communicate and support appropriately enabling achievement of good outcomes.” Another told us, “They engage well and have a good understanding of people’s needs, they work very hard for the people they support.”

There were processes in place that ensured a collaborative and joined up approach to safety that involved the person, along with their representative, staff and other health care professionals involved in their care. We saw examples of joint working in relation to Community Treatment Orders [CTOs] and Clozaril Clinics to support and manage mental health needs.

People told us they were very happy at Hazel Villa and felt safe. Relatives told us they were assured their family members were safe. One relative told us that due to their mental health their family member at times does not feel safe and will ring them. They said, “At such times, staff have responded well, they have got to know [my relative] well and have been able to support them, which is very reassuring to us.”

People were supported to understand safeguarding, what being safe means to them, and how to raise concerns when they don’t feel safe.

Staff told us, and records showed, they had undertaken relevant and current training in recognising and reporting abuse. They showed a good understanding of safeguarding and were confident to report any concerns they may have to management and that they would be addressed and acted on promptly. Management had a good understanding of their responsibilities in relation to safeguarding people.

Staff told us that the service had a no restraint policy and that although training had been provided it would only ever be used as a very last resort.

People were relaxed and comfortable with staff, each other and within their environment. The atmosphere within the service was welcoming and relaxed and staff had positive and caring relationships with the people they were supporting.

People were supported to understand safeguarding through various forums such as resident meetings, key worker meetings and care planning reviews. Management and staff had a good working knowledge of the Deprivation of Liberty Safeguards and the key requirements of the Mental Capacity Act 2005. They put these into practice effectively and ensured that people’s human and legal rights were respected. It was clear from support plan records that the right strategies were used to support a person’s ability to decide for them self where possible.

People who lacked capacity to manage their own financial affairs and benefits were appointed a deputyship. There were robust systems in place to support people with their income and expenditure and protect them from financial abuse.

People were empowered to take positive risks and were protected from harm in a reasonable way. One relative told us, “[My relative] can come and go when they want with staff as they cannot go out alone, but others have their own key and are free to come and go.” Another relative told us, “[My relative] has no concept of risk to themselves or others. I think the systems they have in place do keep people safe. For example, [My relative] has epilepsy and needs a level of support to shower or bath to keep them safe, but [my relative] understands and accepts this.”

People were risk assessed in relation to accessing the community independently. Safety and risk management plans were put in place according to the level of risk based on these assessments. Key fobs were given to those people assessed as safe to come and go independently. Risk assessments for all residents were regularly reviewed and revised accordingly.

People were seen throughout the day coming and going either independently or with a member of staff.

The service engaged in positive risk taking as opposed to avoiding risk which helped to ensure people had choice and remained as independent as possible. Staff were guided about risks to people’s health and welfare from personalised risk assessments and risk management plans.

People’s care and support was provided in a safe, homely, well-furnished and well-maintained environment. Positive feedback was received from people about the environment and people told us how much things had improved. The provider had refurbished and redecorated throughout. People had personalised their rooms and were included in decisions relating to the interior decoration and design of their home. A relative told us, “The home has had a lovely makeover, it now looks like a home, it is lovely.”

Staff told us, “People do appreciate the environment, they have not done anything to damage it, they are appreciative of the improvements made, they now refer to it as ‘their home’.”

The home was free from health and safety hazards. Everywhere had been redecorated with new furniture and all the flooring replaced. The home looked safe and homely. The garden had been improved to make it accessible, clean, tidy and enjoyable.

The provider had systems in place to check, review and address health and safety. Safety certificates were in date. Fire safety was managed well including a current fire risk assessment, regular fire safety checks and fire drills.

People were supported by enough skilled and competent staff who were recruited safely and were sufficiently supported. Relatives gave positive feedback about the numbers and skills of staff. Comments included, “There are enough staff, and they are outstanding with [my relative]” and “Staff have had a lot of training since [my relative] moved in, on a broad range of subjects. Compared to other experiences I would say this company is outstanding” and “I do believe staff have the skills and knowledge they need to support [my relative].”

The registered manager told us staffing had improved, and more permanent staff had been recruited. Staff spoke positively about the staffing levels within the home and told us there were enough staff to provide a safe and effective service. Staff told us that they completed a range of training that ensured they were able to meet people’s needs effectively. They felt well supported. One staff member told us, “Everything here is consistent, we have regular supervision and meetings. We discuss training and understanding, and any additional training needed.”

There were enough competent staff to provide the necessary support people needed to reduce the risk of harm and promote wellbeing and independence.

The provider ensured staffing levels were adequate and that staff were adequately trained to meet the needs of people using the service and ensured fair accessibility to the community.

Learning and development was managed and planned in a way that ensured staff had the opportunity to build on their knowledge base and develop their skills to carry out their roles and meet people’s specific needs. Staff had regular supervision to support them in their roles. Recruitment processes and induction processes were robust.

People lived in a home that was clean and hygienic throughout, and they were protected from the risk of infection.

Staff were clear about their roles and responsibilities around infection prevention and control. We were assured management, and staff were supporting people living at the service to minimise the spread of infection and respond effectively to any risks or signs of infection.

The home was clean and hygienic.

Systems were in place to assess and manage the risk of infection in line with current relevant national guidance. Robust cleaning schedules and infection control and prevention audits were regularly carried out to ensure standards were upheld.

People received their medicines as prescribed, and they were involved in assessing risks with medicines and supported to be as independent as possible. People were supported by staff who understood their individual medicines needs, for example, people who have seizures and people who took anti-psychotic medication. Management of medicines was person centred; people had their medicines stored in their bedrooms in locked medicine cabinets; they told us they were pleased with this change as it gave them privacy and dignity when taking their medicines. One person was being appropriately supported for the gradual discontinuation of a medicine in line with STOMP [Stopping over medication of people with a learning disability and autistic people].

Staff supported people to work with healthcare professionals, so their medicines were checked and reviewed. Staff received training and their competence was assessed to administer medicines safely.

The provider had robust systems in place to ensure medicines were managed safely; to detect errors and take prompt action if any errors were found. However, protocols for ‘as required’ medicines such as those for medicines prescribed to help people who are very distressed could do with more detail. Staff were clear these medicines would only ever be administered as a last resort, but the protocols do not say what if anything else staff should try before administering. Systems were in place for engagement with healthcare professionals in relation to reviews of people’s prescribed medicines at proper intervals, including evaluation of the need for continuation or discontinuation of psychotropic medicines.