Hatfield Manor

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.

This is the first assessment for this newly registered service. This key question has been rated 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 the safe care and treatment and staffing.

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.

Lessons were not always learnt to continually identify and embed good practice. The provider had systems and processes in place; however, these were not fully effective or embedded into everyday practice.

The provider’s processes did not demonstrate a consistent system of reporting, recording and learning for all events. The management team shared incident and accident analyses and minutes from senior staff meetings where events were discussed; however, we found examples where resulting actions had not been completed such as required changes had not been made to people’s care plans.

Staff told us they knew how to report incident and accidents but were not always clear on the outcome of reports they had made. Team meetings and supervisions had not been held with all staff, and it was not clear how learning was shared with staff.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services.

Systems and processes did not always ensure that staff were provided with sufficient information to ensure people were safely admitted to the service. Pre-admission assessments were completed; however, staff told us these lacked information and were not always shared in a timely manner before people moved in. A staff member told us, “We usually get to know new residents when they arrive. Sometimes we are informed on the day, and other times during [handover] that a new resident is expected, often just before they arrive.” Another staff member told us, “The pre-assessment that we receive from management on the day that the new resident arrives is not very comprehensive and lacks information.”

People, and their relatives, were involved in the admission process to the service as much as they were able to and wanted to be. A person told us, “I wasn’t able to visit before coming here but everything was handled by my social worker. I got asked the questions and planned out what help I needed.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider shared concerns quickly and appropriately. However, records relating to safeguarding events were not accurate.

The provider had a system in place to report any safeguarding concerns. A safeguarding log was used by the management team to maintain a record of any referrals made to the local authority, along with any outcome once received. We found this record was blank prior to July 2025, when safeguarding concerns had been raised prior to this date, and did not detail recent safeguarding events that the provider had notified us of. We were assured that all safeguarding events had been reported as needed, however records required review to ensure accuracy.

Staff knew how to recognise and respond to signs of potential abuse. Staff had undertaken training and information about safeguarding people was displayed. A member of staff told us, “I would report to my manager and also to Hertfordshire County Council safeguarding team.” Another member of staff told us, If I suspected abuse, I would report it to management and provide all the information I have. If no action was taken, I would escalate the concern through the appropriate procedures. I have completed safeguarding eLearning.”

People and their relatives told us they felt safe. A person told us, “I do feel safe here. The staff understand what I need.” A relative told us, “I have no concerns but feel they (management) would listen. I’m pleased with the care and attention [person] receives.”

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.

Risks to people’s health, safety and wellbeing were not always robustly monitored and mitigated. Systems and processes in place did not always effectively ensure action was taken to reduce risks to people. For example, some people had experienced weight loss across consecutive months. The ‘monthly weight analysis’ had identified this but failed to record actions being taken in response. The ‘pressure wound overview’ also lacked detail of oversight and action being taken. We raised this with the management team who confirmed that risks were discussed and actions agreed at flash meetings and the clinical risk meeting. A new clinical lead nurse started working at the service during the period of our assessment. The management team told us they felt this appointment would improve the oversight and management of potential risks to people.

We found that risk assessments were present for all aspects of people’s care and most were detailed. Staff told us they were aware of the assessments in place and could explain the actions they should take whilst working with people to mitigate any potential risks. However, during our visit, we identified one person was not being supported in accordance with the guidance in place to mitigate risks whilst they were eating. We intervened and needed to ask staff to take immediate action to remove the risks and observe the person.

People and relatives told us they felt staff knew and understood potential risks to health, safety and wellbeing. A relative told us, “I was involved in assessment and there is a care plan. I get a monthly call to tell me what’s going on. Staff always know current information.”

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

People and their relatives expressed feelings of being safe and secure at the service. A relative told us, “It’s safe. They have door locking systems. Staff are always around and checking.”

We observed the environment to be free from hazards, with equipment in place.

The provider had a system in place to ensure that equipment and facilities were routinely serviced and maintained. Audits and checks on the environment were completed, with action taken when identified as needed.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

We received consistent feedback from relatives that staffing levels were insufficient. A relative told us, “There’s frequent shortage of staff that I mentioned to the former manager. Especially on weekends.” Another relative told us, “No, there is not enough staff, especially at weekends when it’s short staffed all the time.” Some staff also shared concerns regarding staffing. However, some people did feel that staffing was sufficient, “Yes, there’s enough staff. When we want a staff member they are there in seconds.”

The management team told us they completed regular checks on the staffing level to ensure it remained sufficient and used a recognised tool to determine staff numbers. However, we noted this determined the level for the service as a whole and did not consider each unit’s individual requirements. We reviewed completed rotas and found that staffing levels had fallen below the level determined as needed on a number of occasions. The provider confirmed they would continue to review the staffing level and ensure it was reflective of people’s needs and the occupancy of the service.

A staff training matrix and a supervision log were maintained but these did not accurately record all staff working at the service. Regular supervision sessions had not been provided; this included managers and heads of department. A member of staff told us, “I have requested a supervision meeting but am still waiting. I have not received any formal supervision since starting.”

Staff were provided with a range of training; however, some staff had not completed training relevant to the needs of people they were assigned to provide care to. We also found that induction records for staff were incomplete and did not evidence sufficient training had been undertaken prior to staff being deployed onto the rota. The management team confirmed they would complete a review of training for all staff. A recent audit has identified that an increase in compliance with expected levels of training was required, however little progress had been made.

Staff recruitment was safe and all essential pre-employment checks were completed prior to a staff member starting work.

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.

People and their relatives raised no concerns or issues when asked about hygiene or Infection Prevention and Control (IPC). A relative told us, “It’s a very clean place. The bed is changed daily, and cleaning tissues are there. The toilets and bath are cleaned. No infections.”

During our visit, we saw housekeeping staff completed a wide variety of tasks in their daily routine. The service appeared clean; however, we noted a stale odour in one area on the second floor of the building. The management team directed staff to clean the carpets in this area to address this.

IPC audits were completed, with an up-to-date policy in place.

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

People did not always receive their medicines as prescribed. Medicines prescribed to be given at specific times, were not always administered on time. Staff had not contacted the prescriber when time specific medicines were not prescribed at times suitable for a person, for example when they were regularly asleep. This meant people were at risk of experiencing symptoms of their condition or deterioration in their health. One person was prescribed a “when required medicine” [PRN] to support feelings of distress and anxiety. Staff had given more than the prescribed dose and records showed this was a management instruction. We discussed this with the manager who was not aware of the instruction. The GP reviewed the medicine following the incident. However, the medicines administration record [MAR] and supporting care records had not been updated with the new dose and instructions.

Medicines were not always stored in line with manufacturers’ recommendations and expiry dates. Staff recorded fridge temperatures that exceeded the minimum and maximum temperatures. No action was taken to report or resolve this. This meant the medicines may not be safe to use. One person’s eye drops had expired. Staff had administered these on one occasion. We discussed this with the nurse in charge who was aware it had expired; however, the bottle had not been removed from the trolley. This left the person at risk of receiving expired medicines that may not be effective.

Staff completed monthly medicines audits and had identified the electronic medicine administration record [eMAR] system was showing a large number of outstanding medicines. The audit record stated staff had limited knowledge of how to use the system and required training. However, there was no date for eMAR training to be completed by. Staff did not always update MAR charts and care plans when prescribed medicines were changed.

Staff followed instructions to safely administer medicines that needed to be given hidden in food and drink [covertly]. There had been regular reviews of the medicines and appropriate discussion with health care professionals had taken place.