Hafod Residential Home

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• 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.

At this inspection the service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 53 (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 consistently demonstrate a proactive, positive culture of safety. Staff did not always fully act on or explore concerns about safety. Lessons were not always learnt to continually identify and embed good practice.

Audits, including those for care plans, infection prevention and control, medication rounds, and call bell logs, were not consistently completed or fully documented. This limited the provider’s ability to identify patterns, learn from incidents, and embed improvements in care

Reports from external stakeholders, including the lift inspection service and the fire service, highlighted areas of improvement required at the service. Actions to address concerns were not taken promptly to demonstrate that learning from the reports had been embedded into practice.

The service investigated incidents and shared lessons learned with staff through meetings, handovers and supervisions. However, systems for analysing patterns and trends were underdeveloped, limiting the service’s ability to identify emerging themes of risk and act on them proactively. When the inspection team provided feedback, leaders took some swift actions such as, implementing new systems to track incidents more efficiently and identify patterns and trends. However, this was reactive rather than evidence of sustained and proactive safety management.

Despite the above concerns with learning culture, we identified no direct impact on the people who lived at the service.

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 safe admission policies and procedures and maintained strong oversight of risks across people’s care journeys. Staff identified promptly when specialist input was needed and made timely referrals to external professionals, including tissue viability nurses, physiotherapists, and social care teams. They followed professional guidance closely and collaborated effectively to ensure people received consistent, safe care. Some people and relatives confirmed they were kept informed about appointments and care plans, with one relative noting, “They kept me updated about every appointment and made sure everything went smoothly.” This approach supported continuity of care when people moved between services and ensured that safety risks were appropriately managed and monitored.

The provider did not always work well with people to understand what being safe meant to them and how to achieve that. They did not always concentrate on protecting their right to live in safety, free from harassment abuse and neglect

People were not fully supported to understand their rights, including their human rights, rights under the Mental Capacity Act 2005.

The service did not consistently apply or document capacity assessments and Deprivation of Liberty Safeguards (DoLS) applications correctly. For example, one person was restricted by a locked door and could not leave the service. No DoLS were in place, placing them at risk of unlawful restriction. Another person who lacked mental capacity did not have decision specific assessments in line with the mental capacity act in place to guide staff how to act in the person best interest.

However, the care staff received training and demonstrated a good understanding of safeguarding. They took appropriate action when concerns were raised. One staff member told us, “I know how to raise a concern and who to contact if I see anything unsafe.” People and relatives confirmed they felt safe and confident raising issues, with one person saying, “I know that staff will keep me safe here.”

The service investigated and reported safeguarding incidents appropriately and involved relevant partners, including the local authority, police, and CQC.

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.

The service worked with people to understand and manage risks holistically. Staff delivered care that was safe, supportive, and enabled people to do the things that mattered to them. People reported that they were kept informed about risks and told us how staff supported them to stay safe. One person said, “Staff always explain what could happen and help me decide what I want to do.” Some relatives told us the service explained any concerns clearly and involved them in decisions about their loved one’s care. One relative said, “They keep me updated and ask my opinion before any changes are made.”

Care plans on the digital platform contained person-centred details about people’s needs and preferences, which helped staff manage risks proportionately and consistently. Staff told us they reviewed these plans with people whenever possible, and we saw updates that reflected changes in people’s health and wellbeing.

Staff adopted a balanced and proportionate approach to risk that respected people’s choices. For example, one person progressed from being unable to walk to mobilising independently with a walking aid. These positive outcomes demonstrated that staff supported people to take safe risks, promoting independence and improving quality of life.

Staff successfully used de-escalation techniques and positive approaches to manage behaviours, ensuring people’s rights and dignity were protected. One staff member said, “We always try talking to and guiding people”.

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

The environment did not consistently support safe care and required improvement to protect people from potential risks. There were several hazards that placed people at risk. Fire doors did not always close fully when released, and some intumescent strips (fire-resistant seals that expand when exposed to heat) had been painted over, compromising their effectiveness in a fire. Window restrictors were missing in some areas and not health and safety compliant in others, increasing the risk of falls or people leaving the service unnoticed.

The garden area contained hazards, including an unsafe greenhouse, an unlocked shed with tools that could harm people, discarded hazardous materials, an uneven patio surface increasing the risk of falls, and unsecure fencing. These environmental issues demonstrated that risks were not always detected or controlled effectively. Following our feedback, staff documented and addressed the concerns raised, but these actions were reactive rather than evidence of sustained monitoring or proactive risk management.

The provider did not always 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 always work together well to provide safe care that met people’s individual needs in a timely manner.

Staff raised concerns about staffing levels. Staff told us it was sometimes difficult to complete medicine rounds safely, and breaks were missed or taken while remaining with people rather than away from their duties. One staff member explained, “Another pair of hands would make a big difference and help us provide safer care”. Staff also told us, “Staffing pressures impact on our ability to complete care records promptly”.

People and their relatives told us they sometimes felt there were not enough staff available. One person told us, “Sometimes it takes a while for someone to come when I press my buzzer.” Relatives told us that more staff would allow people to engage more in activities and participate in outings.

Following inspection feedback, the service was responsive and reviewed the dependency tool used to determine staff numbers and implemented a revised system that provided reassurances that staffing levels were sufficient to meet people’s needs consistently.

The provider did not always assess or manage the risk of infection.

The service did not always assess or manage the risk of infection effectively. The service did not consistently maintain the premises, equipment, and communal areas in line with safe practice and current infection prevention and control (IPC) code of practice.

Staff did not always follow IPC procedures consistently. For example, some staff did not have barearms below the elbow while supporting people with personal care. This did not align with best practice guidance. Although staff were aware of certain IPC procedures, lapses in cleaning and hygiene practices indicated that monitoring and oversight systems were not fully effective.

Carpets in several areas were visibly aged and could not be cleaned effectively, and radiator covers were rusted, preventing thorough cleaning.

The provider accepted the feedback regarding these concerns.

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 manage medicines safely. Staff sometimes failed to record why a person refused their medicine, did not consistently follow clear and personalised PRN (“as required”) protocols, and did not always maintain good hygiene during medicine rounds. Staff did not always dispose of medicines safely. We observed a staff member carrying a mobile phone during a medicine round, which created a distraction and increased infection control risk. These issues demonstrated that the provider’s systems were not consistently robust enough to ensure safe medicines management.

Despite these concerns, staff managed medicines that required additional safety checks appropriately and followed legal requirements. Staff involved people in decisions about their medicines and in assessments and reviews of the support they required. The new digitalised care plans reflected people’s preferences and support needs, and staff shared medicines information appropriately during transitions, including hospital discharges, and during GP reviews.

Following the inspection, the service provided reassurance on the management of refused or unused medicines that were due for disposal. PRN protocols had been clarified and personalised, and systems were implemented to ensure the staff member completing the medicines round was not distracted.