Hazelcare Head Office

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this service type of supported living. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance. We found improvements were needed to the provider’s governance arrangements around safeguarding, risk and medicines management, and ensuring audits were effective in identifying and making improvements to the service.
 

This service scored 54 (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 have had a shared vision, strategy and culture which was embedded or reflected in practice.
The provider had a clear purpose set out in their policies and company values were discussed within staff inductions. However, the shortfalls identified during this assessment showed that systems had not been embedded to ensure the purpose or values was always being met. The lack of effective processes to safely manage people’s medicines and to fully assess people’s health needs and risks relating to people’s care meant people were at increased risk of harm.
Staff told us they were committed to promoting people’s independence, choice, dignity and wellbeing. One staff member said. “We actively encourage and empower individuals to make their own decisions and support them to maintain as much independence and control over their lives as possible. We respect their choices, preferences, and rights, ensuring they are involved in all decisions that affect them.”
 

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.
The provider had not fulfilled their registration regulatory responsibilities of reporting all notifiable incidents. From reviewing people’s care records, we identified not all safeguarding concerns, police incidents or DoLS authorisations had been reported to CQC as required. This is important information that assists CQC in monitoring services. Following the assessment additional notifications were submitted.

It was not clear during our assessment if some of the senior team understood what constituted support with personal care, this knowledge was necessary to ensure they knew when to inform CQC of notifiable incidents. The provider told us, “I have met with the management team to ensure that the expectations, responsibilities, and procedures relating to personal care support are clearly understood and consistently implemented.”

Staff were consistently positive about the provider’s supportive approach. Staff comments included, “If I ever need help or have concerns, I know I will get the right support. I am really happy to work here because management treats both staff and clients with genuine kindness and respect” and “I don’t feel intimidated to seek guidance or help as management always offers immediate support whenever required. We are encouraged to openly discuss anything with management as they treat us as colleagues with respect.”
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.
Whistleblowing and safeguarding policies supported staff to raise concerns and promote people's safety and wellbeing.
Staff told us they knew how to raise any concerns they had and felt comfortable to do so.
Staff comments included, “I feel able to speak up about concerns without fear, and they are addressed professionally“ and “I do feel able to raise concerns and speak freely, and I have always been listened to when I have done so.”
 

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.
Staff told us they felt supported in their roles. Flexible working arrangements were available to staff. Staff meetings were held online, providing an opportunity for as many staff as possible to be able to attend.
Staff confirmed the provider was fair and treated them equally and they had not experienced any form of discrimination. Staff comments included, “All members of staff are equal, fair, and there is no discrimination. We all have the same rights as well as the same opportunity within the workplace” and “I feel that Hazelcare values diversity and encourages staff to be themselves. I have not experienced or witnessed any discrimination.”
 

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.
The provider's governance systems, processes and procedures for assessing risk and monitoring the quality and safety of the service were not fully effective. They had failed to identify the shortfalls found during this assessment, which meant opportunities to drive improvement and reduce risks had been missed. Audits and checks had failed to identify that some people’s risk assessments and care plans lacked sufficient detail and guidance for staff or did not contain current information.
In addition, governance processes had not identified the shortfalls in other areas including relating to medicines optimisation and safeguarding, as detailed in this report. The provider had allocated various tasks to senior staff based within the services but did not have a system for checking if these tasks were being completed. These issues demonstrated that governance arrangements were not always effective in identifying concerns, driving improvement and ensuring the service was consistently operating in line with regulatory requirements and best practice. The provider acknowledged the shortfalls identified and took some immediate actions to begin addressing them.
 

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.
Health and social care professionals told us they felt some improvements were needed to communication with the provider. A health and social care professional told us their experiences of partnership working varied, depending on the supported living service. They said, “The first service appears well managed, with good communication, effective partnership working and a clear focus on achieving positive outcomes for the person supported. However, within the second service, communication has been often frustrating and create barriers to effective partnership working. Information is not always shared promptly, and professionals can find it difficult to access the appropriate staff members directly.”
 

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Opportunities for learning and improvement had not always been effectively identified through the provider's governance and quality assurance processes. As identified during this assessment, auditing and oversight systems had failed to recognise the shortfalls relating to the assessment of risk, medicines optimisation and regulatory reporting requirements. The provider had a quality action plan it was working on. However, this did not include actions identified in provider audits and it was unclear how managers had oversight of all the actions which had been identified.
The provider was receptive to feedback, acknowledged where improvements were required and took some immediate actions to address concerns identified during the assessment. Whilst this demonstrated a willingness to learn and improve, further work was needed to ensure quality assurance systems were sufficiently robust to identify issues promptly, drive continuous improvement and sustain positive outcomes for people.