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Archived: Hazelmere Extra Care Scheme Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 6 March 2018

We undertook a focused in inspection on the 24 January 2018 and 1 February 2018

Our last comprehensive inspection of Hazelmere Extra Care Scheme took place on the 13 and 14 March 2017 and the service was rated as Good.

Following that inspection we received concerns in relation to safe care and treatment and consent. As a result we undertook a focused inspection to look into those concerns.

This report only covers our findings in relation to those topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Hazelmere Extra Care Scheme on our website at www.cqc.org.uk.

The service provides care and support to people living in specialist ‘extra care’ housing. Extra care housing is purpose-built or adapted single household accommodation in a shared site or building. The accommodation here is bought or rented, and is the occupant’s own home. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for extra care housing; this inspection looked at people’s personal care and support service.

Planned, day-to-day personal care can be provided by staff based at the site or from elsewhere, including ordinary domiciliary care agencies. There is a care provider based at the scheme able to provide emergency support to everyone living there. Not everyone living in extra care housing receives regulated personal care.

There are 106 apartments and also access to communal facilities such as a bistro, library, gym, laundry and an assisted bath room.

There was a registered manager. This is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found the service had breached a number of regulations. You can see what action we told the provider to take at the back of the full version of the report.

The registered provider failed to identify, assess and manage risks to the health and safety of people of using the service. Medicines were not managed safely and some people did not get their medicines as required.

The provider did not have effective quality assurance processes to monitor the quality and safety of the service provided and to ensure that people received appropriate care and support.

Processes and procedures were in place to ensure people were protected from abuse and harm. Staff spoke about the actions they would take if they thought a person was at risk of harm. However, we found that not all concerns were reported and fully investigated.

People were not always supported to have maximum choice and control of their lives. Staff did not have a clear understanding of restrictive practices. There was a lack of documented evidence around a person’s ability to make a decision or to make an unwise choice which may have put them at risk.

The service ensured trained staff were deployed to support people. The registered provider had a robust recruitment process in place, with staff being fully checked before starting working with people.

There were enough staff employed to carry out all the visits that were required. People told us they were regularly supported by the same team of care workers.

People were supported to maintain good health and access to healthcare professionals.

Feedback was regularly sought from people using the service and staff.

Staff said they felt supported by the management team. Staff we spoke with confirmed they could raise issues with the management and said they were “Approachable”.

Inspection areas

Safe

Requires improvement

Updated 6 March 2018

The service was not always safe.

Risks to people were not always identified and where risks had been recognised these were not fully mitigated against.

The service did not ensure medicines were administered safely and in line with the instructions on people's prescriptions.

Staff demonstrated a good awareness of safeguarding but incidents were not always reported.

Effective

Requires improvement

Updated 6 March 2018

The service was not always effective.

The registered provider had not completed Mental Capacity Assessments and 'best interests' decisions for people who may have lacked in mental capacity to make decisions for themselves.

Training, supervisions and appraisals were up to date and monitored by the service.

People were supported to maintain their diet and hydration.

Caring

Good

Updated 28 April 2017

The service was caring.

People who used the service and family members said staff were kind, caring, helpful and friendly towards them.

Staff supported people to maintain their dignity, privacy and independence.

People had access to a range of information about the service.

Responsive

Good

Updated 28 April 2017

The service was responsive.

Care plans were person-centred and information was up to date.

People said they didn’t have any current concerns or complaints about the service. A complaints policy was in place and people knew how to make a complaint if they were unhappy.

Well-led

Requires improvement

Updated 6 March 2018

The service was not always well led.

The registered provider did not have effective quality assurance processes to monitor the quality and safety of the service provided and to ensure that people received appropriate care and support.

The service had a clear management structure in place. Staff said

they were happy working at the scheme

People and staff were encouraged to express their views about the services.