Hartford Hey

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 remained good. This meant people were safe and protected from avoidable harm.
 

This service scored 69 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.
The provider had effective systems for reviewing incidents and used them as learning opportunities. For example, when one person experienced a fall in their bedroom, staff recorded this on a falls sheet and completed a body map to document injuries. Senior staff reviewed the incident, updated the person’s care plan the same day, and considered how to reduce the risk of it happening again. Learning from incidents was shared during handovers and recorded in the communication book so all staff understood what had happened and what to monitor.
 

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.
When people moved into the home, a comprehensive pre-admission form was completed using information gathered from social services, as well as the person and their family members. The form detailed all the person’s care needs. Staff we spoke with told us they were given time to read this information prior to supporting the person to ensure the person’s needs were met.
People had a personal information sheet in their care files which was used if they required hospital admission. This included key details hospital staff would need on arrival, along with contact numbers for the home and the person’s next of kin.
 

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.
There were systems and policies in place to support safeguarding practice. The provider had up‑to‑date safeguarding, Mental Capacity Act (MCA) and whistleblowing policies, and staff had completed relevant training. Staff we spoke with understood how to recognise and report concerns. Safeguarding notifications were sent to the local authority appropriately and in a timely manner.
 

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
People had care plans and risk assessments to guide staff on how they could mitigate risk to the person while supporting them to be as independent as possible. The provider had documented discussions with people about the use of sensor mats in their bedrooms, ensuring they understood the mat would alert staff if they were moving around and this was to keep them safe. Mental capacity assessments had been completed to confirm people could make this decision and were comfortable with this level of monitoring. This demonstrated the provider understood their responsibilities under the Mental Capacity Act (MCA) and did not place restrictions on people without their consent.
 

The provider did not always detect and control potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.
Some environmental risks required further attention. On the upper floor, fire doors opened onto an external escape route that was not routinely used in the evacuation plan. The provider had taken steps to manage the risk through individual risk assessments for people with nearby bedrooms; however, the risk itself remains and ongoing vigilance is essential. Window restrictors were in place in most rooms above ground level, but a small number required replacement; the registered manager told us this would be addressed immediately.
Despite these issues, the environment was generally safe, well maintained and supported people’s wellbeing. Clear signage helped people navigate the home. The provider had ensured all required gas, electrical and equipment safety checks and certifications were up to date. A recent fire service audit confirmed good compliance, with all follow‑up actions completed. We observed safe use of pressure‑relieving mattresses, with daily checks on these completed by senior care staff.
 

The provider did not always make sure staff were recruited safely. For example, recruitment records we looked at contained gaps, including missing interview records and staff identification. This meant the provider could not evidence how they assured themselves staff were suitable for the roles they were employed in. When we raised this with the registered manager, they explained they kept interviews quite informal and while they did take notes, they didn’t always keep them afterwards. Not all staff had completed all their mandatory online training courses, although the registered manager had begun to address this and had a system to monitor ongoing non-compliance. They gave us assurance this was being prioritised.
Staff told us they received good support and supervision from the provider and their induction to the service was good. We observed adequate staffing levels at the time of our visit. Staff we spoke with said they all work well as a team and support each other.
 

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.
Although the kitchen was visibly clean, cleaning records for this area were not available, which limited the provider’s ability to evidence consistent monitoring. The provider told us they had previously used a full cleaning rota and assured us they would reintroduce this to strengthen oversight.
Staff had completed infection prevention and control (IPC) training. Personal protective equipment (PPE) was available and used appropriately, and hand sanitiser was accessible throughout the home. Domestic cleaning records for other areas of the home were well maintained.
 

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The provider had effective systems for the safe administration and management of medicines. Staff were trained and assessed as competent annually, and audits were used to monitor practice. Controlled drugs were managed safely, and fridge storage was appropriate. External medication audits completed by the NHS medicines team concluded there were no areas of significant concern. We observed staff talking with people about their medications prior to administering them. Medication reviews were conducted monthly in conjunction with the GP who visited each person separately.