Harefield Lodge

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 regulations related to safe care and treatment due to concerns in involving people to manage risks, management of safe environments, staffing, infection, prevention and control and medicines management.

This service scored 59 (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 from incidents to identify improvements to safety.

We observed staff listening to people and responding to their concerns. Staff knew what incidents to report and how to report them.

The provider investigated incidents thoroughly and shared outcomes with people and relevant stakeholders. We saw evidence of change resulting from incidents that had occurred. The registered manager shared learning with staff through staff communication channels and team meetings.

The registered manager told us they received safety alerts from the government, local authority and CQC. This informed them of upcoming risks so the provider could take appropriate action to mitigate these risks.

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.

The provider had a robust admissions policy. The registered manager was able to explain the process, which included visiting people in their current environment, assessing them to establish suitability and compatibility prior to moving in, visits for the person to the home, and ensuring any referrals for support and additional training for staff were in place.

People were consistently supported when they were distressed. There was a focus on planning for a good day and understanding what had caused people distress so positive changes could happen.

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. The provider mostly shared concerns quickly and appropriately.

People had access to easy read information, or staff who knew them well to help them raise concerns.

Staff knew how to protect people from abuse and who they would report any concerns to both internally and externally.

The service mostly shared concerns appropriately by following the correct process and ensuring these were reported to the relevant agencies Where we identified a missing referral and notification we spoke with the registered manager about this, who sent a retrospective notification.

The provider identified when people were potentially being deprived of their liberty,complied with the basic principles of the Mental Capacity Act 2005,and made timely applications for authorisation under the Deprivation of Liberty Safeguards.Theyreviewed care arrangements to ensure people subject to, andawaitingfor,DoLS authorisations were subject to the least restrictions possible.

The provider worked well with people to understand risks; however, documents did not always contain accurate information. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were assessed for risk of falls, risk of choking and risks relating to medical conditions. Some care plans did not contain enough information, for example, care plans relating to bowel management, choking and personal emergency evacuation plans (PEEPs). Incomplete information increased the risk of people not receiving the right treatment. However, we were assured staff knew people well. The registered manager told us they would review and update these plans.

The registered manager shared with us an example of when a person had been supported to undertake a potentially risky activity. They worked with the person and made adaptions to increase the person’s independence and to reduce the risk.

The provider did not always detect and control potential risks in the care environment. They did not always make sure that equipment, facilities and technology supported the delivery of safe care.

A fire risk assessment had been undertaken in November 2025. The report highlighted concerns with people’s PEEPs not being personalised and with weekly fire alarm testing not being consistently completed. Both these concerns remained during our inspection. Regular audits were undertaken to ensure the environment and equipment remained safe to use; however, they failed to identify these concerns. Therefore, the audits failed to drive improvement.

Fire evacuation drill records contained minimal detail which did not show if people had been involved in the evacuation and successfully escorted to the assembly point.

The concerns we found with fire safety placed people at risk in the event of a fire.

Other health and safety checks were completed, with concerns identified reported to the management team or appropriate person for further action.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Staff received effective support and supervision.

Staff had completed statutory and mandatory training and competency assessments. The provider ensured staff attended bespoke training relating to supporting people with a learning disability and autistic people.

However, a person had a medical condition; staff had not received specific training relating to this, which meant we could not be assured they would recognise different presentation types or understand individual risk factors. Staff did not receive positive behavioural support training. From the incident forms we reviewed, we could not be assured staff had always picked up on early signs a person was becoming distressed. The registered manager told us they had made a referral to their positive behaviour support team for additional support which would include additional training for staff.

The required pre-employment checks had not always been completed. The provider’s recruitment policy was not in line with current legislation. Whilst this had not had a negative impact on people, there was an increased risk of the provider recruiting unsuitable staff. The registered manager told us they would raise this with the recruitment department.

The provider’s recruitment processes which were fair and ensured there was no disadvantage based on any specific protected characteristic.

The provider did not always assess and manage the risk of infection. They did not always detect and control the risk of it spreading.

The provider had an up to date infection prevention and control (IPC) policy that reflected current national guidance and staff attended IPC training.

Decor was tired in places, especially in people’s en-suite bathrooms where floors were stained. Some radiators had rust on, and 1 person’s headboard was in state of disrepair. The registered manager told us they had reported these concerns.

The home was not always clean. During both our on-site visits there was dust in places, including on skirting boards, the stairs and in people’s bedrooms. Some people’s toilets were also heavily stained. There was no cleaning rota in use in July 2026. The registered manager told us a new one was in the process of being devised. Following our inspection visit, the registered manager shared with us the new cleaning schedules and sent us some pictures showing some of the cleaning issues we found had been resolved.

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

‘As required’ (PRN) medicines protocols did not always contain enough information. We reviewed 5 protocols, which did not detail when staff should seek medical advice if the concern persisted. However, people’s records confirmed staff were administering PRN medicines appropriately and seeking medical advice when needed. For 1 person, their medication care plan did not detail their preferences in relation to medicines administration. The registered manager told us they would revisit the PRN protocols and the care plan and add this information.

There was a robust medicines policy in place. Staff received medication training, and their competency was checked to ensure they understood the requirements for the safe administration of medicines. People had received their medicines as prescribed.

The registered manager told us people’s annual health reviews considered stopping over medication of people with a learning disability and/or autism (STOMP) . This ensured psychotropic medicines were not inappropriately prescribed or overused. This meant people were less likely to be at risk of medical restraint.