CQC report explained · a residential care home
What the CQC found at Hazelwood House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2023
Requires Improvement; inspectors found kind care and good staffing, but risks, medicines, care records and quality checks were not consistently managed safely.
This was an unannounced inspection over three days. Inspectors spoke with 9 people, 6 staff and a visiting professional. They reviewed care plans, medicines records and other service documents.
The home was rated Requires Improvement overall. Safe, Effective, Responsive and Well-led were also Requires Improvement. Caring was rated Good. Inspectors found people were treated kindly, supported to make choices and helped to access food and healthcare.
There were important shortfalls. Risk plans did not always give staff enough guidance. Individual instructions for some medicines were missing. Care plans did not always record people's needs, preferences and wishes clearly. Quality checks had not found these problems.
The provider supplied some further information after the inspection, including behaviour support plans, medicines protocols and evidence of audits. However, the rating changed from Good at the previous inspection to Requires Improvement, and CQC said it would monitor the improvement work.
Kind and respectful care
People said staff were kind and polite. Inspectors saw staff supporting people patiently, offering choices and protecting their privacy and dignity.
“They [staff] are kind and caring. However, I don't get too much help just general assistance, I am able to do a lot of things by myself.” from the report
Staffing and recruitment
The rota showed shifts were covered, people said there were enough staff, and recruitment checks had been completed.
“Normally they have enough staff, and I don't have to wait long.” from the report
Food and drink
People were offered choices, including cultural and religious meals. They could eat in communal areas or in their rooms.
“If don't like the meal they give me something else instead.” from the report
Access to healthcare
The home worked with health professionals and helped people access appointments and treatment when their health changed.
“One external professional told us that they worked, "Very well together with the home.” from the report
Safeguarding awareness
Staff had safeguarding training and knew how to report concerns. The home had worked with the local authority to investigate safeguarding concerns.
“If I had any concerns, I would talk to the deputy manager or registered manager, I can also speak to the police or you (CQC).” from the report
Risk plans lacked detail
seriousPlans for falls, transfers, deteriorating health and distress behaviours did not always tell staff clearly how to reduce risks or provide consistent support. This increased the risk of harm.
“However, plans to guide staff to manage such risks were not always in place.” from the report
Medicines guidance was incomplete
seriousIndividual protocols for medicines given when needed were not available during the inspection. Night staff were also not always trained or signed off as competent to support people with medicines.
“The lack of clear individual PRN guidance was a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Care records were not personal enough
seriousSome care plans did not clearly record people's life history, hobbies, preferences or health needs. This could make consistent, person-centred care harder to provide.
“The lack of comprehensive person-centred care plan is a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Quality checks missed problems
seriousAudits of care plans, risk assessments and medicines did not identify the shortfalls found by inspectors. The home's quality assurance systems were therefore not fully effective.
“The lack of effective quality assurance monitoring systems was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Activities lacked variety
minorActivities were available, but several people said they wanted more variety. CQC recommended that the home seek further guidance about suitable activities.
“However, a number of people told us that they would like to have a greater variety in activities offered” from the report
- 01What has changed in each person's risk plan for falls, transfers, deteriorating health and distress behaviours since the inspection?
- 02Are individual protocols for all medicines given when needed now kept in the home and available to staff?
- 03Which night staff are trained and signed off as competent to support people with medicines?
- 04How have you updated care plans to include each person's history, preferences, hobbies and health needs?
- 05What new activities are now available for people who wanted more variety?
This was an unannounced inspection prompted by concerns about safe treatment and care; inspectors assessed all five key questions and infection prevention and control, and reviewed three care plans and medicines records. This explanation was written from the published report of 4 July 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, September 2022
Hazelwood House was rated Good; inspectors found people were safe, but asked for clearer as-needed medicines guidance and more consistent visitor testing.
This was an unannounced inspection on 16 August 2022. One inspector spoke with one person, three relatives and four staff. They reviewed care records, medicines records, staff recruitment and supervision files, and management records.
The inspection was prompted partly by a serious injury after an incident. The report says it did not examine the circumstances of that incident, but it did examine possible risks from falls. Inspectors found no evidence that people were at risk of harm from this concern.
The home was rated Good overall, with Safe and Well-led also rated Good. The other three areas were not inspected during this visit, so their previous ratings were used for the overall rating.
Falls risk management
People's falls risks were assessed with clear guidance for staff. The home also sought advice from occupational therapy and physiotherapy to support safe movement and independence.
“We found that risk assessments contained sufficient details guiding staff to ensure people were safe and the risk of falls were minimised.” from the report
Staffing and recruitment
Inspectors found enough staff to meet people's needs. Recruitment checks, including references and criminal record checks, had been completed.
“There were enough care staff to ensure that people received consistent care to meet their needs.” from the report
Safe medicines
Medicine records were completed correctly and stock matched the records. Staff who gave medicines had training and competency checks.
“People's medicines administration records (MARs) were completed correctly and medicines stock held by the service was consistent with stock levels documented on the MARs.” from the report
Open management
The management team monitored care, accidents, falls, weights, care plans and the environment. Relatives and staff said their views were listened to.
“The quality of care people received at the service was clearly monitored via the provider's quality monitoring processes.” from the report
As-needed medicines guidance
needs fixingSome people were prescribed medicines to take when needed. The report says personalised protocols were not yet fully developed, although the manager contacted the prescriber during the inspection and began this work.
“However, we discussed with the provider the importance of developing personalised PRN protocols” from the report
Visitor testing checks
minorThe home had a visitor testing system, but inspectors were not asked to show evidence of a lateral flow test. Records showed testing happened most of the time, not routinely on the inspection visit.
“The service did not ask us for evidence of a lateral flow test.” from the report
- 01Have personalised protocols now been completed for every medicine prescribed to be taken as needed?
- 02How do you check that staff follow each person's falls risk assessment and guidance?
- 03How are visitor lateral flow tests checked and recorded now?
- 04What actions were taken after the serious injury and the two safeguarding concerns about fall prevention?
- 05What were the ratings for Effective, Caring and Responsive at the previous comprehensive inspection?
This was a focused inspection of Safe and Well-led, including infection prevention and falls risks; the other key question ratings were not inspected and were carried over from the previous inspection. This explanation was written from the published report of 21 September 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Hazelwood House
7 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2022Goodstayed GoodSafe: GoodWell-led: Good
- July 2021GoodSafe: GoodWell-led: Good
- December 2020Inspected but not ratedSafe: Inspected but not rated
- September 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- October 2015Goodstayed GoodSafe: Good
- August 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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