Hazelcare Head Office

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.

This is the first assessment for this service type of supported living. This key question has been rated 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.

The service was in breach of legal regulation in relation to people’s safe care and treatment and safeguarding.

We found improvements were needed to ensure the provider identified and took appropriate actions when there were safeguarding concerns, effectively assessed and mitigated risks for people and supported people with their medicines safely.
 

This service scored 47 (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 investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff were completing incident reports. However, we found some instances where no records could be found explaining how damage to property had occurred. For example, 1 service had cracked glass in an external door, but no incident record could be found which explained when or how this occurred. This meant there was no record of what had occurred or of any actions taken to ensure people were safe.

Incident reports did not always include sufficient detail about events or actions taken to reduce risk and ensure people were safe. We found there had been a delay in the review of some incidents and registered managers did not have oversight of all incidents, in line with their policy.

Staff told us learning relating to people’s care was discussed. However, lessons were not always learnt, embedded and well documented. For example, incident reports recorded occasions where a person had not returned to their home and was uncontactable. Following these incidents measures which could reduce risk had not been recorded in the person’s care plan as being discussed with them.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Initial assessments were completed with people before they moved into the service. One person had been provided with information about their new home which was tailored to their communication needs. A relative told us their transition to move to the service had worked well and said, “I really liked the way staff who would be working with them came to visit.” A health and social care professional told us,” The provider undertook an excellent transition from an out-of-county placement.”
One person told us they had requested and been supported to move from one of the provider’s other services to another and said, “I like it here, is nice and friendly.”
However, a health professional told us there had been, “Delays in notifying us of new residents and supplying their care plans.”
 

The provider did not 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 avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

The provider had not always reported safeguarding incidents as required. We identified a safeguarding concern which had not been reported to the local authority safeguarding team and CQC as required. We found the risks to people from this concern had not been sufficiently assessed and mitigated. We fed this back to the provider and during the assessment they took action to mitigate these risks.
The provider had investigated a recent safeguarding concern and put in place an action plan to address shortfalls identified with a person’s medicines. Although the investigation stated medication procedures had been reviewed and medicine records audited, this process was not effective at addressing the medicines management shortfalls we found during this assessment.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. Supported living is a social care arrangement where individuals receive care and support in their own homes or shared accommodation, promoting independent living. Community Deprivation of Liberty Safeguards (DoLS) refers to Court of Protection orders required to legally authorise restrictive care for individuals who lack mental capacity and reside outside of hospitals or care homes. Some people were subject to Community DoLS authorisations. It was noticed 1 person’s DoLs authorisation had expired and the provider had not taken any action to follow this up. Their mental capacity assessments had not been reviewed to ensure they provided an up-to-date assessment of the person's capacity. Information about restrictions people were subject to as a condition of their DoLS authorisation were not always clearly recorded in their care plans.
We found notifications had not always been submitted to CQC as required. These included incidents reported to the police and the outcome of a community DoLS application.
People and staff had information available to them to enable them to raise a concern. Staff had completed safeguarding training and told us they understood their responsibilities in relation to safeguarding. One staff member said, “I understand my responsibility to recognise, respond to and report any concerns without delay.”
 

The provider did not 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.
The service completed risk assessments for people. However, not all risks to people had been sufficiently assessed. For example, where people had health conditions such as Parkinson’s disease, diabetes or epilepsy care plans contained limited information for staff on the support people needed to safely manage their condition. Where people had risks associated with self-neglect, these had not always been sufficiently assessed or documented putting them at risk.
Some people had positive behaviour support (PBS) plans which explained the support they needed when they experienced behaviours of distress. One person was prescribed a medicine they could take as required when they felt distressed. However, their PBS plan did not record details of the medicine or when it should be administered.
People’s risk assessments had not always been updated. For example, we found some people’s medicines risks assessments did not contain current information about their support needs in relation to their medicines or about the safe storage of their medicines. This meant staff did not always have access to clear and accurate guidance to support people safely.
Staff told us about specific agreements they had agreed with people to manage areas of risk. However, we found there was insufficient information about these agreements in people’s care plans.

People were supported to take positive risks. For example, where risks had been identified when people spent time independently in the community, risk assessments clearly recorded the measures in place to ensure the safety of the person and others.

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.

The provider had processes including maintenance meetings to identify and address environmental risks. However, we found some environmental risks which had not been identified or addressed in a timely manner. For example, 2 people’s showers did not fully meet their physical needs. We were not assured timely action had been taken to address these issues. One person’s wardrobe was not secured to the wall and there was a risk this could fall over causing injury. We raised this to the provider who took immediate action to address these areas. During our assessment we were informed wet rooms would be installed for people and the wardrobe had been secured to the wall.

One service had an external door with a large crack in the glass. The provider had taken some actions to arrange for the glass to be replaced and seek some assurances about safety, the doors were still in use and the risk of this had not been assessed. Another service had a quantity of broken glass in the garden area. The provider was not aware of how or when either of these incidents occurred.

The provider did not always have environmental risk assessments, for example one service did not have a fire risk assessment. Where services did have a fire risk assessment it was unclear how identified actions were monitored to ensure completion. Health and safety audits were completed monthly but had not identified the shortfalls we found during our assessment.

Fire drills took place to ensure people could be evacuated safely in the event of a fire. Personal Emergency Evacuation Plans (PEEPs) assessed the level of support people required in the event of a fire or other emergency.
 

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Managers and senior staff supported staff through regular supervisions and annual reviews. They completed medicines competency assessments and spot checks of staff practice, which included seeking feedback from the person being supported.
New staff received an induction which included both an introduction to the organisation and shadowing of experienced staff. A staff member told us, “When first starting at the service, I received full induction, completed all required training and had shadowing opportunities before starting to work autonomously.”
Managers used a dashboard to provide oversight of staff training, supervisions, appraisal and other staff checks. Staff completed regular training, this included the Care Certificate. Specific training to meet people’s needs, such as diabetes training was provided to staff who supported people with those conditions.
People were observed to be cared for by suitable numbers of staff. People told us staff treated them well. One person told us, “Staff are happy to help.”
Recruitment procedures were followed including Disclosure and Barring Service (DBS), right to work and reference checks, however we found only one reference had been obtained for one staff member, this was not in line with the provider’s policy and procedure. Interview records were completed. However, candidate responses to asked questions were not recorded but given a score, this meant records did not show how the person had demonstrated suitability for the role.
 

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider did not have systems to ensure best practice was followed to always maintain effective infection prevention and control (IPC). While some services were clean, other services were found to be unclean. For example, 1 service’s kitchen had dirty and damaged pots and pans within cupboards. Staff told us people may put away these items without cleaning them. Cleaning schedules were followed for each service which were being signed off by staff. However, they didn't appear to always be effective. For example, checks of kitchen cupboards were not included in the cleaning schedule, although staff were aware people may put away items they had not cleaned.
Some service’s communal bathrooms had stained and damaged flooring, 1 of these bathrooms also had a radiator which had rust on its surfaces. This meant there was a risk effective cleaning could not be undertaken to ensure the risks of infection was minimised.
Provider IPC audits were completed. However, they had not identified and addressed the issues we found during our assessment.
Staff completed IPC training and had access to personal protective equipment (PPE). People had guidance available in their care plans about how to support them to maintain their own personal hygiene and a clean environment.
 

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.
The provider’s systems for medicines governance were ineffective, some records were inaccurate and incomplete, and people were exposed to significant risk of avoidable harm.

The provider did not have an effective system to record and monitor people’s medicines stock.
The provider told us stock levels of all medicines were recorded in electronic handover notes each day. However, records we reviewed did not show stock levels of medicines were being consistently recorded. This increased the risk of medicine shortages, missed doses, and medication errors, which could result in people not receiving their medicines as prescribed.
Where people were prescribed medicines to take as they required, protocols were not always in place to record how and when the medicine should be administered. Where topical medicines such as creams were prescribed, there were no body maps in place to guide safe use.
People’s prescribed medicines listed in their care plans did not always match the electronic system used to record the administration of medicines.

The provider told us they had not identified any medicines errors. However, we found potential medicines errors which had not been identified. Medicines administration was allocated to more than 1 member of staff on duty on an electronic system. As a result, multiple staff members were able to record that a medicine had been administered. It was not always clear which staff member had administered a medicine and there was a risk that a medicine could have been administered more than once. We found gaps in medicines records which could indicate a person had missed a dose of their prescribed medicines. The provider informed us senior staff were expected to review these events with staff allocated to administer people’s medicines and record any actions taken in care notes, however this process was not always completed.

The provider had not ensured they had an effective system to ensure time specific medicines, such as medicines prescribed to manage the symptoms of Parkinson’s disease were administered at consistent times. This meant the medicine could potentially be less effective.
Medicines audits were completed but had not identified the issues we found.
People told us they were happy with the support they received to manage their medicines.
We informed the provider of our concerns in relation to medicines management. They provided us with information about immediate actions they had completed and steps they planned to take to improve the safety and oversight of medicines.