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Archived: Hazelmere Extra Care Scheme Requires improvement


Inspection carried out on 24 January 2018

During an inspection to make sure that the improvements required had been made

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

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 carried out on 13 March 2017

During a routine inspection

This inspection took place on 13 and 14 March 2017 and was announced. The provider was given 48 hours’ notice because the location provides a domiciliary care service and we needed to be sure that someone would be available.

Hazelmere Extra Care Scheme is a domiciliary care service providing support to adults within the Hazelmere complex. Extra Care Housing is housing designed with the needs of older people in mind and with varying levels of care and support available on site. People who live in Extra Care Housing have their own self contained homes, their own front doors and a legal right to occupy the property. Hazelmere were registered with the Care Quality Commission on 28 August 2015 and this is their first inspection. The service currently provides care and support to 41 people.

There was a registered manager in place at this service. They had been registered since September 2015. A registered manager 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.

People told us they were happy with the service provided and that the staff were caring, kind and friendly. People said “The staff are brilliant”, “I have no complaints” and “Staff are kind.”

Staff told us they enjoyed working at the service and providing support to people within the complex. They said they were supported by the management team and they appreciated that out of hours support was also available should they need it.

Care plans were well documented and up to date. They gave clear guidance to the staff team on how people wanted to be supported. Risk assessments were undertaken for a variety of tasks which included moving and handling, nutrition, falls and the environment. These were reviewed regularly and up to date. The management of medication was safe.

Staff were aware of how to report a safeguarding concern. They understood policies and procedures were available to safeguard people from harm and told us they would not hesitate to report any concerns.

Staff had received a range of training that included moving and handling, safeguarding, medication and health, safety and fire. A range of other training was available to the staff team specific to their role. Staff told us that the training was good. Staff had access to supervision sessions, annual appraisals and were invited to attend regular staff meetings.

Staff recruitment files showed that robust recruitment processes were in place. Staff attended an induction prior to working alone in the complex. Staff told us that they worked alongside an experienced staff member before working alone. They confirmed the induction process was good and that they had the information they needed to perform their role.

People had access to information about the service. They said that they knew the information was in their care folder and some people had read this. Other people said they were not bothered about the folder but knew the information was available. An initial assessment was undertaken by one of the management team prior to the service starting.

A complaints policy was available and each person had this information within the care folder. Processes were in place to deal with any complaints received. A number of complaints had been received by the Care Quality Commission and these had been investigated by the local authority. They found that the majority of the issues raised were unfounded and that on the whole these had not been substantiated.

Quality assurance processes were in place which included observations of staff to ensure that care and support standards were being maintained. Regular reviews of people’s care were also undertaken to ensure information remained up to date. Audits were undertaken in relation to the service provided