Harwood House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.The service was in breach of legal regulation in relation to management of medicine, staff recruitment, and duty of candour.

This service scored 47 (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 always ensure the system in place for recording and managing accidents and incidents was followed consistently. This is important to help ensure that remedial actions can be taken to prevent similar incidents from happening again. The management team explained the process of managing these events. However, the information was not always clearly recorded on the forms as we had to seek further explanations for different events. The management team provided information but also acknowledged the process needed improving to ensure information was captured well. There was some analysis of incidents and accidents to identify themes and trends and lessons learned reviews for recent events in 2025. However, this area needed improving to ensure all staff were able to be involved and contribute to the process to ensure there was effective and meaningful learning and measuring outcomes and impact of the services provided. Relatives said they were kept informed of any incidents or accidents which happened to their family member in the service.

We discussed duty of candour with the manager, including which incidents are required to be reported to the Care Quality Commission (CQC). The duty of candour is a legal and professional requirement for health and social care providers in the UK to be open, honest, and transparent with people (or their families) when something goes wrong with their care or treatment, causing, or having the potential to cause, significant harm. There had been notifiable safety incidents where duty of candour would apply. The provider had a policy that set out the actions staff should take in situations where the duty of candour would apply. However, the provider did not always ensure they followed the process of duty of candour. People were supported to receive the required treatment after the injuries for example attend the hospital for further treatment. We reviewed information to check how the regulation had been followed when notifiable safety incidents happened. There was lack of evidence the provider followed the regulation and their own policy to complete all the actions set out. We could not be assured the provider had acted in an open and transparent way with relevant persons in relation to the incidents. The management team were not able to provide us further evidence this process was consistently followed and actioned.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. People and relatives were involved, informed and supported by the managers and the staff team who worked together with professionals to ensure continuity of care, including when people moved between different services or required temporary stays at the hospital. Relatives agreed they were involved and informed regarding their family members wellbeing as and when they required treatment from different services. The manager was recently appointed to the post. They explained how they have been working together with professionals and others, through a collaborative, joined-up approach, to ensure safety and continuity of care was a priority throughout people’s care journey. The manager and the staff team understood the risks to people across their care journeys and ensured information about people was available to help manage any risks in a proactive and effective way. The manager added professionals involved were very supportive of the service and worked proactively with them to look after people. Staff ensured the care and support was planned and organised with people, including effective communication and liaising with professionals for different aspects of care and support that would ensure continuity and positive outcomes for people. The manager had been establishing ways for staff to share feedback and gain learning that would help make improvements and bring about better outcomes for people, for example meeting staff individually to discuss different matters. Where the manager picked up any gaps in practices, this was discussed with staff to come up with solutions and suggestions to ensure appropriate action was taken.

The provider did not always share concerns quickly and appropriately. The provider did not always ensure their system in place to protect people from abuse and improper treatment was used effectively. We found some incidents where safeguarding alerts were not raised to ensure they were investigated properly. By failing to inform the relevant authorities of the allegation of abuse, this placed people at risk of ongoing harm or abuse. The management team informed us after the site visit, they have submitted the information to the local authority. We have considered this under the key question of well-led. People felt safe at the service and could ask staff for support or help. Relatives agreed people were safe at the service. They said, “I think Harwood house is the best place for [the person] because of the loving care [the person] receives there; I think [the person] is very safe” and “Yes very safe, there is always staff around so if [the person] is upset or feeling down, there is always someone to turn to”. Staff were able to explain the safeguarding process. They knew how to identify and raise incidents and who to report to. Staff were assured the management would respond to concerns. Staff knew there was a whistleblowing policy and would use it, although staff felt they could raise concerns to their managers. One staff member said that people were reminded of their rights via posters in the home and by letter.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).The provider had made DoLS referrals for people to ensure appropriate legal authorisations were in place when needed to deprive a person of their liberty.

The provider did not always ensure clear records were in place to support people’s risk management. For example, one person had issues with drinking and eating. It was reported there was some deterioration in physical health state thus the person was placed on repositioning, and fluid and food monitoring. There was inconsistency in the record the person’s needs for example, the frequency of repositioning was not indicated. The amount of fluid taken within 24 hours was not indicated. There was no clear evidence the person was offered enough fluid regularly or if fluids were, offered but the person declined. Some people had special mattresses to support their skin integrity. We found that one person’s weight did not match the setting on the air mattress device. This meant the person was at risk of skin damage from the wrong pressure mattress setting. We noted this to the senior staff who did adjust the setting according to the weight. This was also discussed with the manager, and they told us this was added to the audit as part of the checks. Another person had specific food allergies, but these were not consistently noted to ensure they were not at risk of an allergic reaction. Some people had bed rails in place. However, records such as capacity assessments did not clearly demonstrate how risks relating to having bed rails and people’s wishes had been considered in a meaningful and balanced way. This meant inconsistent monitoring of risk management could put people at potential risk of receiving incorrect care or treatment.

The provider did not always detect and control potential risks in the care environment. There were established systems for monitoring of the safety of the premises and the living environment. However, we found some aspects needing improvement. For example, we found some cupboards including high voltage were unlocked when they should be locked. Some cupboards had wires and different items stored inappropriately that could increase the risk of fire. There were items such as a big chair and 2 wheelchairs stored under the stairs and next to the cupboard of high voltage, increasing the risk of electric shock. We raised this with the management team and most of these issues were addressed immediately. Fire drill records did not have staff names captured, and no learning outcomes recorded to review if the drills were completed correctly. We discussed with the maintenance staff the importance of keeping such records to ensure participation and good knowledge of evacuation process. We were provided with the list of staff and dates after the site visit.

We looked around with the manager to check if the service was designed to ensure it met the needs of people with dementia. The manager was very engaged in the review and we identified areas of good practice to support people living with dementia, but we found some areas needed improvements. For example, there were no handrails along the walls, except for one part of the corridor where there was a slope. Lifts were not easy to find due to no signage, however these had large control buttons which were also lit up around the buttons to support people to use them. There was no signage from social areas to the toilets. The toilet doors were not painted in a distinctive colour, and there was no clear signage to support people to access them. The toilet seats and rails were not contrasting, but in a white colour with the tiles and walls being the same. We discussed and agreed that although there was a lot of artwork around the home, this was not designed to enhance orientation and wayfinding. The manager agreed they had some areas to work on and improve. Other checks were completed to make sure equipment, facilities and technology supported the delivery of safe care.

The provider did not operate effective and robust recruitment and selection procedures to ensure they employed suitable staff. The provider did not ensure the required information according to the regulation was gathered before staff started working at the service which put people at risk of being supported by unsuitable staff. In 9 staff files we found discrepancies with gathering full employment history; employment; evidence from previous employments related to health and social care regarding staff's conduct and verifying the reasons for leaving; staff fitness to work in the service and right to work in UK checks. The Disclosure and Barring Service (DBS) checks were not always completed prior to staff commencing work at the service. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. The provider did not ensure required checks were consistently completed at the time of recruitment. Not having all required recruitment information before staff started work, could put people at risk of being supported by unsuitable staff.

We reviewed the training matrix for staff training that indicated a number of staff had not yet had their training refreshed as required for a variety of topics. This included oral suction, wound care, dysphagia, moving and handling that are necessary to support people’s needs. Although there was a training plan established by the provider to address multiple gaps in the staff training, having staff supporting people without up-to-date knowledge and skills, could put people at risk of harm or injury.

Relatives’ feedback about staffing numbers was mixed. Some said, “Well no I do not [think there is enough staff] and the weekends are not good; I think they need to improve…the number of staff” and “I think there could be more staff particularly in the evenings and weekends”. Other relatives were positive regarding staffing. They said, “I would say so yes, there always seem to be staff about when I visit” and “I have never thought about shortness of staff as there always seem to be someone close by to speak to or offer me a drink.” Staff reported that staffing levels were sufficient. They supported each other to cover the shifts or used regular agency staff as much as possible to support continuity of care to people. The relatives were complimentary about staff’s skills and support they provided. They said, “Yes they seem to be [trained and skilled]; the care team seem to know what they are doing and they are so caring and kind and that shines through” and “Yes they seem to be [trained], there are obviously nurses who are qualified and also the care staff; they are all very patient and kind”.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The manager and the staff team monitored and managed the risk of infection regularly. The manager told us the work ongoing regarding managing infection prevention and control risks, so it was dealt with promptly. The manager worked together with the staff team and other professionals to support people’s recovery when they had any infections. People were protected as much as possible from the risk of infection because premises and equipment were kept clean and hygienic. The service had dedicated staff to ensure they maintained their roles and responsibilities around infection prevention and control. Staff used appropriate personal protective equipment to help protect people from the risks relating to cross infection. People and relatives confirmed they did not have any issues with cleanliness of the service. Relatives were complimentary about the service and environment. They said, “Cleanliness is fabulous and the safety of the home is good, and the food is also lovely”, “I think it’s very clean and always smelling of apples”, “Oh it is very good, I have never noticed any uncleanliness at the home or in [person’s] room or bathroom, it’s always clean”.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The provider needed to make some further improvements to the management of medicines. For example, we found some gaps in medicine administration record (MAR) sheets where it was not clear if the medicine was administered. People were prescribed ‘as required’ (PRN) medicine to manage different ailments or conditions. However, there were no protocols in place to guide staff when to administer the medicine to ensure it was given consistently. People did not have the necessary safeguards in place when on specific types of medicines such as steroids. We also found hand-written notes on MAR sheets regarding changes of the prescriptions. But there was no information to evidence this has been discussed and agreed with a medical professional. We found medicine still available that was supposed to be discarded however this was not done which increased the risk of error. One of the clinical rooms was very warm however there was no monitoring of the temperature. This meant the senior staff could not assure the medicine were kept at the right temperature. Some people had paraffin-based creams, and risk assessments to ensure fire safety had not been completed to support safe usage. We found expired equipment such as electrodes, urine dipsticks, glucose machines, peptic liquid, linctus, dressing, plasters and an EpiPen which was accessible to staff. This meant the provider could not be assured people received their medicines safely and as prescribed and this placed people at increased risk of harm.