Hadfield 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 staffing.

This service scored 56 (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 have a proactive and positive culture of safety based on openness and honesty. Leaders did not always investigate safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider was unable to evidence incident reviews or investigations. The incident documentation received was the initial review from the staff member who had completed the appropriate paperwork, however, the registered manager’s response to the incidents was not available. Incidents must be reviewed and investigated by competent staff to make sure that action is taken to remedy the situation, prevent further occurrences and make sure improvements are made as a result.

The provider shared details of low-level harm incidents with the local authority weekly. However, the provider was unable to demonstrate some incidents being submitted. Therefore, we were not assured all incidents were being escalated to the local authority appropriately.

The provider was unable to demonstrate any evidence of learning from incidents or concerns. Staff meeting minutes did not indicate discussions regarding learning from concerns and incidents and staff told us learning from such events did not occur.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care.

The provider did not always obtain all key information when someone moved into the care home. For example, the provider did not have information regarding how a person’s covert medicines should be administered. Following feedback being provided, the provider contacted the pharmacy who arranged to review this.

People had hospital passports in place, which contained key information shared with professionals during hospital visits. However, some hospital passports had missing or incorrect information, including allergies. Senior leaders said hospital passports were rarely used, with paramedics often requesting the latest medicine administration record instead. The provider had not documented this procedure to ensure safe transitions to hospital.

People’s care plans and care plan review forms were not always up to date so we could not be assured they reflected people’s current needs.

The registered manager told us they went out to see people before they moved into the care home to ensure their suitability. They liaised with the person, their families and friends to capture the key details of the person before deciding on whether they would be suitable for the care home.

Relatives told us that the transition into the service for their loved one’s was seamless and straightforward. They explained how the registered manager visited them before they moved in and felt the communication was excellent.

The provider did not have effective oversight of safeguarding concerns. However, staff did have a good understanding of safeguarding and people felt safe at the care home.

The provider did not have robust systems and processes in relation to safeguarding concerns. The provider failed to demonstrate effective scrutiny and oversight of their safeguarding incidents. CQC had not received statutory notifications for all allegations of abuse. For example, there was a resident-on-resident incident in which abuse was alleged which was not shared with CQC.

The provider had a yearly training planner which outlined which modules staff should complete each month. For February 2026, staff were tasked with completing the safeguarding adults and safeguarding children training. In July 2026, below half of staff had completed safeguarding children training and just above half had completed safeguarding adults training. Training should be updated at appropriate intervals to ensure staff are kept up to date with national safeguarding arrangements.

However, people appeared to be treated well by staff. There were no signs people were fearful, withdrawn or neglected. Staff had a good understanding of their responsibilities in relation to safeguarding and how to escalate concerns if they had them.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. The provider had evidenced on their action plan how they would follow up the DoLS applications with the local authority.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People’s care plans and risk assessments did not always contain clear, accurate or sufficiently detailed information to guide staff in providing safe and effective care. This included a lack of specific guidance for responding to behaviours that challenge, incomplete risk assessments relating to modified diets, swallowing risks and risks associated with mental health needs, and contradictory information regarding people’s skin integrity and moving and handling needs.

Some assessments and one-page profiles had not been reviewed or updated to reflect changes in people’s needs. Records also indicated that not all staff had reviewed people’s care information, which increased the risk that staff may not have a full understanding of people’s individual risks and support needs.

Following our onsite feedback, the provider made some improvements and provided evidence of actions taken. However, some records continued to lack sufficient detail, and further work was required to ensure all care plans and risk assessments were accurate, current and consistently reflect people’s needs. The provider told us the lead senior had been allocated responsibility for reviewing care records and that a ‘Resident of the Day’ approach would be introduced to support ongoing review and improvement.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The premises were well maintained and contained dementia friendly signage. Any issues were raised by staff and addressed promptly by the maintenance team. The provider ensured regular checks regarding the building’s safety were being completed, and action was taken where any issues were identified.

People, relatives and staff spoke positively about the environment. One person said, “It’s very pleasant here, it is always clean and there are never any bad smells.” No staff raised any concerns regarding the environment or people’s equipment.

However, fire drills appeared to be being completed at a similar time, meaning staff on different shifts had not completed a fire drill/evacuation in 2026.

The provider had a fire risk assessment completed in 2023 which identified concerns. The registered manager explained how improvements had been made but had not requested a new fire risk assessment from an external provider to check that improvements were satisfactory. The provider said they would address this.

The provider did not always make sure staff received effective support, supervision and development.

Although people and relatives felt there were sufficient staff to meet their needs, most staff reported increased pressure following changes to shift patterns and said they were rarely able to take breaks. Staff also raised concerns about sickness levels, particularly on night shifts, which had resulted in some shifts being covered by 2 staff rather than the planned 3. However, the provider’s dependency tool indicated staffing levels were sufficient.

The provider was unable to demonstrate that staff received regular, effective supervision or annual appraisals. Following our feedback, supervisions were completed; however, records were largely generic and did not evidence meaningful, individualised discussions regarding staff performance, wellbeing, training or development.

The provider was also unable to locate evidence of previous medication competency assessments. Following inspection feedback, senior leaders told us competency checks were completed for all relevant staff but did not provide evidence, despite these being requested.

Mandatory training was being completed on a rolling programme; however, records showed that only around half of staff had completed some required training modules. Recruitment records were also incomplete, although the provider took prompt action to update these following our feedback.

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 provider managed the risk of infection effectively. Systems were in place to prevent and control the spread of infection, and concerns were shared promptly with relevant agencies when required.

The care home was clean, tidy and was free from unpleasant odours. Staff followed infection prevention and control (IPC) procedures and used personal protective equipment (PPE) appropriately.

However, staff’s training completion rate for IPC was low.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The provider had not ensured medicines were always managed safely. Records relating to covert medicines were incomplete and did not include clear, pharmacist-approved guidance regarding the agreed method of administration.

People’s medicines care plans also lacked sufficient detail, including information about covert medicines, condition-specific risks and the actions staff should take in relation to medicines such as anticoagulants.

Some people’s ‘when required’ (PRN) medicines did not have appropriate protocols in place, despite this having been identified during a previous audit. Following our feedback, the provider took action to complete missing documentation; however, some protocols remained outstanding and one contained inconsistent dosing information.

The provider was unable to evidence that medicines competency assessments had been completed, and night staff had been administering some ‘when required’ (PRN) medicines without appropriate medicines training or competency checks. Following feedback, senior leaders told us all staff had been trained, and competency assessments were completed but did not evidence this, despite this being requested.

Despite requesting evidence of training completion rates for medicines training, we did not receive these. Therefore, we were not assured all staff had up to date training in relation to medicines which posed a potential risk.

Weekly medicines audits lacked sufficient detail, were not always fully completed and were not consistently undertaken.

However, medicines were stored securely, clearly labelled and appropriately organised.