Hafod Residential Home

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question Good. At this assessment the rating has changed to requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

This service scored 67 (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 make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them and/or their relatives.

The service did not consistently ensure that assessments fully reflected people’s individual needs. Communication care plans required improvement and did not contain enough detail to support staff and lacked information on strategies and tools to use to support effective communication with people. Several relatives expressed that they would like to be more involved in assessments, showing that people and their families were not always fully engaged in the process. One relative told us “I don’t always know what’s happening with my relative’s care.” I’d like to be more involved when assessments are done so I can help make sure their needs are fully understood.”

The provider was in transition from paper care records to a new digital platform. Whilst care records on the digital platform were reviewed, and peoples care needs regularly updated to reflect changes in people’s health, communication, and wellbeing; the paper care records were outdated. This meant, overall, the records did not always include person-centred details about people’s preferences, risks, and abilities, which supported staff in delivering safe, appropriate, and tailored care.

The provider planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff assessed and understood risks relating to people's care. Staff provided care, treatment, and support that was evidence-based and in line with current good practice standards. People and their relatives were mostly involved in discussions about their care. The service supported people to have strong relationships with their relatives, Staff applied appropriate clinical tools to assess people’s health, mobility, skin integrity, and nutritional needs, ensuring care was tailored to individual requirements, evaluate people’s health and care needs effectively

People’s nutrition and hydration needs were met in line with current guidance. Mealtimes were warm and welcoming, with people expressing satisfaction with the quality, choice, and presentation of food. One person told us “The food is lovely here and I can choose which one (meal) I like.” Staff monitored food and fluid intake and supported people to maintain balanced diets. Adjustments were made where needed to meet people’s individual preferences and health requirements. The service ensured staff were up to date with legislation, professional standards, and evidence-based guidance. Leaders encouraged learning and the adoption of new approaches to improve care delivery, and staff applied this knowledge effectively in practice. People and their relatives confirmed that staff demonstrated competence, knowledge, and understanding of how best to meet individual needs.

The provider worked well across teams and services to support people. They made sure people only needed to tell the story once by sharing assessments of needs when people moved between different services.

Staff collaborated effectively to assess, plan, and deliver people’s care, treatment, and support. They had access to up-to-date information to understand individuals needs and make informed decisions. The service was in transition replacing paper-based care plans, with a new digital system to improve consistency in care delivery across shifts and roles. One staff member said, “I can check the care plan on the electronic device before my shift, so I know exactly what everyone needs today.”

Staff obtained relevant information about people upon admission and during respite stays; however, gaps remained in assessing and documenting communication needs. The service had started making improvements to ensure communication preferences were fully understood and reflected in care plans going forward. Staff worked closely with external professionals, including physiotherapists, tissue viability nurses, and social care teams, to ensure interventions were timely, effective, and coordinated. For example, one person had previously been unable to walk; coordinated support from care staff and physiotherapists enabled them to progress mobilising independently with a walking aid. One person said, “The physiotherapist came and helped me walk again, and staff kept encouraging me, now I can get around with my walker.” This approach reflected a strong focus on person-centred, preventative care.

Staff demonstrated effective teamwork within the service. People and relatives mostly reported that staff communicated well and coordinated support effectively. One relative said, “The staff always talk to each other, so I don’t have to repeat myself, and everyone knows what my mother needs.” Another person told us, “They work together really well, and it makes me feel safe knowing they all know what’s happening.”

The provider supported people to manage their health and wellbeing to maximise their independence, choice, and control. Staff supported people to live healthier lives and, where possible, reduce their future needs for care and support.

Staff empowered and supported people to manage their own health, care, and wellbeing needs. They understood individual preferences and involved people in reviewing their health wherever possible. One person told us, “The activities coordinator helps me keep fit, and I do the stretching exercises with them every morning.” People attended regular health checks and assessments, including GP visits, hospital appointments, and other routine checks. Delays in accessing some services were not caused by the service but reflected general availability.

Staff encouraged healthier choices, including promoting balanced nutrition, hydration, and activity. One relative commented, “The staff always make sure he eats well and drinks enough, and they help him with exercises that keep him moving.” Health risks were identified early, and proactive measures were taken to prevent deterioration. For example, staff monitored skin integrity closely. One person had previously had a persistent skin ulcer, but this had healed under their care. A staff member said, “We check skin every shift, and any marks or changes are noted straight away so we can act quickly.”

Most people were actively involved in their care and wellbeing. Staff ensured that interventions supported independence and positive outcomes. Coordinated support from staff, including physiotherapists and other healthcare professionals, helped people maintain and improve their health, wellbeing, and functional abilities.

The provider routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff monitored people’s care and treatment effectively to ensure positive outcomes were achieved. They used recognised assessment tools to evaluate health, mobility, skin integrity, nutrition, and hydration, and reviewed care plans to reflect changes in needs. The transition to digital care plans supported staff in tracking progress and ensuring interventions were person-centred.

People experienced demonstrable improvements in their health and wellbeing. For example, one person’s previously persistent skin ulcer healed under the service’s care. Staff and leaders used this information to identify areas for improvement and adjust care delivery accordingly.

The service encouraged learning from care and treatment outcomes, incidents, and feedback to continuously improve the quality of care. Staff reflected on results during team meetings, supervisions, and handovers, ensuring that lessons were learnt and changes applied so that care standards were maintained. People and relatives reported that staff understood individual needs and worked effectively to support positive health and wellbeing outcomes.

The provider did not always tell people about their rights around consent and did not always protect their rights when delivering care and treatment.

People's capacity and ability to consent was not always assessed in line with the requirements of the Mental Capacity Act 2005. For example, one person with a cognitive impairment was assumed to lack capacity for all decisions, rather than being assessed for individual aspects of their care. This blanket approach meant that people’s rights to make informed decisions were not consistently respected. Not all people and or their relatives felt fully involved in discussions about their care and treatment. Staff sometimes relied on standard care documentation rather than personalised discussions to record consent. We raised the issues identified and these were addressed in a timely manner.

Despite these shortfalls, we observed staff asking people for consent before providing care and supported people to understand the care and treatment being offered. One person told us, “They ask me before they help me with anything, and I can say yes or no.”