Hazeldene House improved from Requires Improvement to Good overall, with previous breaches of regulations 12 and 17 now met through stronger risk management, medicines practice and quality auditing. Well-led remained Requires Improvement due to the absence of a registered manager, lack of structured staff meetings and minor gaps in PRN medicines records and end-of-life care planning.
Concerns (7)
moderateMedication management: “Where medicines were prescribed 'as required' such as painkillers or medicines for anxiety, instructions were not clear, and records not always completed.”
moderateLeadership: “The service did not have a registered manager at the time of our inspection; the manager had left the service within the previous few weeks.”
moderateGovernance: “the service was not always consistently managed and well-led.”
minorPerson-centred care: “not all relatives who had signed tenancies had been made fully aware of alternative options, either for the provision of accommodation or their care.”
minorEnd-of-life care: “Some end of life care plans lacked details. The provider was aware of this and had plans in place to address this.”
minorOther: “Some relatives told us the range of activities was limited and they would like to see more offered to people.”
minorCommunication with families: “The deputy manager did not have structured meetings with groups of staff”
Strengths
· Safe care and treatment with comprehensive, up-to-date care plans and risk assessments
· Effective infection prevention and control measures in place
· Staff well-trained, including diabetes refresher training and safeguarding
· Robust quality monitoring with regular audits across infection control, medicines and care plans
· Person-centred care reflecting cultural, spiritual and individual preferences
Quality-Statement breakdown (19)
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Adapting service, design, decoration to meet people's needsGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
responsive: Meeting people's communication needsGood
responsive: Planning personalised careGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Continuous learning and improving care; duty of candourRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Working in partnership with othersRequires improvement