Kazlum Support Ltd improved from Requires Improvement to Good across all three inspected key questions (Safe, Effective, Well-led), having resolved prior breaches of Regulations 9, 11, 13, and 17. The service now demonstrates safe, person-centred care underpinned by effective governance, strong staff training, and a genuinely open and improvement-driven culture.
Strengths
· Comprehensive risk assessments covering all aspects of support, enabling safe community participation tailored to changing needs.
· Medicines managed safely with STOMP participation, specialist insulin training, computerised alerts, and independent audit oversight.
· Significant improvement in MCA compliance: staff trained, capacity assessments documented, best interest decisions clearly recorded.
· Person-centred care plans developed with PBS specialist input, leading to improved outcomes, communication and community engagement.
· Effective governance with wide-ranging audits overseen by independent consultant and local authority QAIT, driving continuous improvement.
Kazlum Support Ltd was rated Requires Improvement following a focused inspection that identified breaches of Regulations 9, 11, 13 and 17 around person-centred care, consent, safeguarding and good governance, with nine safeguarding referrals made post-inspection. Punitive use of positive behaviour systems, missing mental capacity assessments, ineffective governance and a closed/defensive management culture led to enforcement conditions on the provider's registration.
Concerns (17)
criticalSafeguarding: “Systems were not operated effectively to identify where people may have experienced abuse or been put at risk of harm. It had not been identified that some people had been subject to degrading treatment”
criticalSafeguarding: “Following our inspection, we made nine safeguarding referrals to the Local Authority that had not been identified by the service to ensure people were safely protected from harm.”
criticalConsent / capacity: “People were subject to daily restrictions such as limited use of technology, restrictions on what they could spend their money on and restrictions around food. No mental capacity assessments had been completed”
criticalConsent / capacity: “Kazlum Support were managing people's finances on their behalf without the legal authority to do so.”
criticalPerson-centred care: “Peoples care was not always delivered in line with standards, guidance and the law. This was a breach of Regulation 9”
criticalPerson-centred care: “Positive behaviour systems had been used in a negative and punitive way. Records showed staff using 'star' rewards and the removal of treats as punishment.”
criticalGovernance: “Governance processes were ineffective and did not hold staff to account, keep people safe, protect their rights or ensure good quality care and support.”
criticalGovernance: “There were no systems in place to audit care records, which meant managers did not analyse information to ensure people were supported in line with their support plans”
criticalIncident learning: “they had not identified themes and trends of positive behaviour systems being used in a punitive way, nor recognised this as abuse.”
moderateLeadership: “The Registered Manager had limited involvement in the day to day running of the service and did not participate in this inspection process.”
moderateLeadership: “Management were defensive of poor and outdated practice, and written records indicated a culture which lacked respect for people”
moderateCare planning: “There was insufficient information within people's support plans to enable staff to effectively support and understand their mental health needs.”
moderateStaff training: “Training records indicated staff should complete Mental Capacity Act training every three years, however, 13 out of 34 staff had not completed the training within the past three years.”
moderateStaffing levels: “There aren't enough staff at this house as a few have left and they haven't got any more staff for our house.”
moderateCommunication with families: “The service did not always act on the duty of candour appropriately.”
moderateRecord keeping: “Notifications were not always submitted to CQC in line with the regulations.”
minorMedication management: “there were no audits undertaken or checks of medicines recorded.”
Strengths
· Staff completed regular training, with 20 out of 24 staff achieving or working towards NVQ qualifications.
· Safe recruitment systems with DBS checks and references obtained prior to staff starting work.
· Appropriate infection prevention and control measures were in place during the COVID-19 pandemic.
· Risks to people's safety were identified and assessed, with people supported to access the community safely.
· People were supported to eat and drink enough, choose food and be involved in meal preparation.
Quality-Statement breakdown (14)
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongNot rated
safe: Assessing risk, safety monitoring and management; Using medicines safelyNot rated
safe: Staffing and recruitmentNot rated
safe: Preventing and controlling infectionNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
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effective: Supporting people to eat and drink enough to maintain a balanced diet
Not rated
effective: Supporting people to live healthier lives, access healthcare services and supportNot rated
effective: Adapting service, design, decoration to meet people's needsNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candour; Working in partnership with othersNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated