We carried out a review of the data available to us about Hazelgrove Care Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Hazelgrove Care Home, you can give feedback on this service.
We found the following examples of good practice
The provider ensured current government guidelines in relation to COVID-19 were followed by staff and visitors to reduce the risk of infection to people living at the service. This included checks for visitors upon arrival.
People had individualised COVID-19 risk assessments and care plans which provided guidance for staff to follow so they knew how best to support people to reduce the risk of COVID-19 outbreaks.
People and staff took part in regular COVID-19 whole home testing. People and staff who tested positive followed national guidance and self-isolated for the required amount of time.
All staff working at the service were fully vaccinated.
Staff had received training in infection prevention and had access to personal protective equipment (PPE), such as masks, gloves and aprons, to mitigate the risk of the spread of infection. There were sufficient stocks available, and staff were seen to be wearing PPE appropriately.
The provider had reviewed and updated their practice and procedures following any changes to the national guidelines to reflect best practice.
People’s experience of using this service:
The provider met the characteristics of ‘Good’ in all areas. More information about this is in the full report.
Some people raised concerns about the numbers of staff available to support them. Analysis of call bell response times showed that call bell requests were normally answered quickly. During the inspection, we did note that there were enough staff to meet people’s needs. However, the registered manager told us they would review how staff were deployed to reassure people that staff were available for them when needed. The risks to people’s health and safety were assessed. However, the level a person’s bed was set to did not relate to the required setting within their care record. This could have placed their safety at risk.
People felt safe at the home and staff understood how to protect them from avoidable harm. People’s medicines were managed safely, and staff understood how to reduce the risk of the spread of infection. Processes were in place to investigate and to learn from accidents and incidents.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice.
People received support in line with their assessed needs. Although we did find one area of pressure care management that needed to be completed more thoroughly to ensure the person’s healing pressure sore was monitored effectively.
Staff training was largely up to date and they received on-going assessment of their practice. People received the support they needed to maintain a healthy diet. People at risk of weight loss or gain and dehydration were referred to health specialists. People had access to other health and social care agencies where needed. The environment had been adapted to support people living with dementia and/or a physical disability.
Most people found staff to be kind, caring and respectful. People felt they were treated with dignity and respect. People’s independence was encouraged. People were supported to make decisions about their care. The home offered a caring environment for those living with dementia. People’s records were stored securely to protect their privacy.
People’s care records contained guidance for staff to provide person-centred care and support. We found one issue in relation to the guidance to support a person with their diabetes. People were supported to take part in the activities, hobbies and interests that were important to them. People living were dementia were offered opportunities to take part in tasks that were interesting to them and/or relevant to their past. Complaints were responded to in line with the provider’s complaints policy. End of life care plans were in place where needed.
Audits were effectively used to assist the registered manager and the provider in identifying and acting on risks in an effective and timely manner. The performance of the registered manager was assessed by regular reviews carried out by representatives of the provider. Most people felt the registered manager would act on concerns raised. Staff felt supported by the registered manager. People and relatives had been given the opportunity to give their views about how the service could develop and improve.
There was a continued focus on learning, development and improvement. The registered manager had a good understanding of the regulatory requirements of their role.
Rating at last inspection:
At the last inspection the service was rated as Good (Report published 23 November 2016).
Why we inspected:
This was a planned inspection based on the previous rating.
Follow up:
We will continue to review information we receive about the service until the next scheduled inspection. If we receive any information of concern, we may inspect sooner than scheduled.
The service had a registered manager in place at the time of our inspection. 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 were supported by staff who knew how to recognise abuse and how to respond to concerns. Risks in relation to people’s daily life were assessed and planned for to minimise the risk of them coming to harm.
People were supported by enough staff to ensure they received care and support when they needed it. Medicines were managed safely and people received their medicines as prescribed.
People were supported by staff who had the knowledge and skills to provide safe and appropriate care and support. People were supported to make decisions and staff knew how to act if people did not have the capacity to make decisions.
People were supported to maintain their nutrition and staff were monitoring and responding to people’s health conditions.
People lived in a service where staff cared about them and showed compassion. People’s privacy and dignity was respected and they were treated with respect.
People were involved in planning their care and support. Activities in the service were being established to ensure people could follow their hobbies and interests. People were supported to raise concerns and these were listened to and acted on.
Systems to monitor and improve the quality of the service had been implemented and were effective. People were involved in giving their views on how the service was run and were supported by a well-managed team of staff.
We inspected the service on 30 November 2015 and 1 December 2015. Hazelgrove Care Home is registered to provide accommodation and personal care for up to 40 older people living with or without dementia. On the day of our inspection there were 36 people living at the home.
The home had a registered manager who was available during our inspection. 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.
Although people told us that they felt safe, we found that not everyone was being looked after in line with their care and support plan and this was putting them at risk of harm. Risks were not always being managed safely. Staff were not always acting in accordance with agreed support plans to keep people safe.
The provider had systems in place to recognise and respond to incidents and allegations of abuse although these were not consistently being followed.
People received their medicines as prescribed and overall medicines were managed safely.
Staffing levels were sufficient to meet people’s needs although staff often felt rushed. Staff absence negatively impacted on time needed by senior staff to carry out their roles effectively This had affected the quality of record keeping. Records did not always provide clear guidance for staff to follow in order to respond to people’s needs and support them effectively.
Recruitment procedures were good ensuring that only people suitable to work at the home were appointed. The premises were well maintained and safe.
Staff received appropriate induction and training. This gave them the knowledge and the skills to support the people who used the service. Staff support was an area where improvement was required to ensure staff felt listened to and valued.
Overall people’s rights were protected under the Mental Capacity Act 2005. External professionals were involved in people’s care as appropriate.
People received sufficient to eat and drink although the dining experience could be improved.
People felt listened to and were supported to make decisions and choices. People’s privacy and dignity however was not always respected and promoted. People enjoyed a range of activities.
A complaints procedure was in place and staff knew how to respond to complaints. There were systems in place to monitor and improve the quality of the service provided. People living at the home and the staff team had opportunities to be involved in discussions about the running of the home although staff did not always feel that they suggestions were acted upon. The manager was in the process of making changes to the service to improve the overall quality of the care and support provided.
One person using the service said, “The staff are very good, very nice to me, better than where I was before, they kept telling me I had to sit down but here I can walk around without being told what to do.”
We observed staff delivering care to people using the service and saw they were kind in their approach. We saw there were activities for people living at the service to get involved with if they wanted to. We saw people had their weight recorded as their care plan instructed and action had been taken if they had lost weight. We also saw fluid and food charts had been completed so that people’s intake could be monitored.
We looked at the environment and found it was generally clean and well maintained. We visited the service during the afternoon and found there was a smell of urine in the main lounge area. We saw the lounge carpet was due to be deep cleaned the day after our inspection.
People received the care and support they required to improve their health and well-being. Care records were generally written in detail and provided clear guidance to staff members.
There were systems in place to make sure people were safeguarded. Staff members had received training and confirmed how they would report any possible abuse. People told us they felt safe and would be able to speak with someone if they had any concerns.
We found the home had been redecorated within the last year and was clean and tidy. Furniture was secure and people could walk around safely.
Staff rotas and training information showed there were enough qualified, skilled and experienced staff available to meet people's needs. People using the service said there were not always enough staff available and we found this may be due to limitations in how the were able to summon staff.
There were systems in place to regularly check and monitor the way the service was run.