Hafod Residential Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of legal regulation in relation to governance at the service.

This service scored 57 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The service was working towards ensuring there was a shared vision and strategy developed through a structured planning process in collaboration with people who use the service. However, at the time of our assessment this was not yet fully embedded.

Relatives reported limited formal opportunities to collaborate with the service. The service lacked structured processes to monitor and review progress against strategic goals or to fully understand the broader needs of people. Whilst staff did their best to demonstrate compassion, listening culture was not always evidenced due to staffing pressures.

At the time of our assessment, the culture of the service did not fully evidence that each individual person was at the centre of decisions about their lives due to the above shortfalls.

Despite these gaps, staff understood equality, diversity, and human rights and demonstrated compassion and respect in daily practice.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively,

Leaders did not always fully understand the context in which the service delivered care, treatment, and support. Leaders were generally committed to the organisation’s culture and values and some leaders had opportunities to strengthen their skills, knowledge, and experience to support leading consistently with confidence and clarity. However, the oversight of day-to-day operations and risk management was affected.

Relatives reported limited formal opportunities to be involved in decisions about the service, and staff described gaps in communication during shift changes. One staff member noted, “The new staff that are covering from across the road [a sister service] had not communicated anything from when I have been off.” This showed that day-to-day oversight could be inconsistent. Structured succession planning and formal monitoring of staff development had not been fully implemented, which limited leadership continuity and resilience. Leaders tried to encourage human rights, however there were missed opportunities to fully engage the people with learning disabilities as part of their community, for example, due to the limited outings.

Despite these gaps, leaders were visible and approachable. Staff described the manager as “supportive and listens” and said they respond promptly when issues were raised. Leaders promoted a compassionate and inclusive culture, and staff felt able to raise concerns, make suggestions, and act in people’s best interests. Staff demonstrated integrity and modelled inclusive behaviours through respectful and dignified care.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Leaders and staff promoted a culture of openness, honesty, and transparency. Staff reported feeling empowered to raise concerns and confident that their voices would be heard without fear of detriment. When issues were raised, leaders acted sensitively and confidentially, investigating appropriately and responding in a timely manner. Staff felt supported in speaking up, and leaders encouraged continuous improvement through listening and acting on feedback.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Leaders actively promoted a culture of equality, diversity, and inclusion. Staff reported that managers were supportive, approachable, and listened to concerns or suggestions, with one noting the manager was “supportive and listens.” Staff felt empowered to raise issues and contribute ideas, demonstrating that their voices were valued and acted upon. Leaders modelled inclusive behaviours, and staff described care and workplace interactions as respectful and dignified. Reasonable adjustments were made where needed, and there was a clear focus on ensuring staff from all backgrounds could participate and be heard. While some formal monitoring of equality and inclusion initiatives was limited, overall, the service fostered an equitable and inclusive culture for its workforce.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The service was developing new management and governance arrangements, but these were not fully effective or embedded. Leaders were visible and approachable, and staff understood their day-to-day responsibilities. However, systems to monitor performance, manage risks, and oversee quality were inconsistent. For example, there were gaps in communication when covering shifts and succession planning.

Environmental and operational issues were not always addressed in a timely way. While the service had created an action plan for maintenance and system improvements, some, were not clearly tracked or followed up before inspection. Missing documentation, including parts of pre-admission assessments and some ReSPECT forms meant there was limited information about people’s individual care needs.

Auditing and review systems were underdeveloped which increased the risk of unsafe care. Care plan audits did not always record key issues, such as skin integrity, and risk assessments were sometimes incomplete. Other audits, including those for infection prevention, medicine rounds, call bells, and incidents, were either not in place or had only recently been introduced as new tracking systems.

While leaders were supportive and approachable, gaps in oversight, record-keeping, and systems to monitor quality meant that governance arrangements were not consistently effective, limiting the service’s ability to assure the quality and safety of care.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement

Staff and leaders worked openly and collaboratively with a range of external organisations and community partners, including local healthcare services, social services, and advocacy groups. They shared learning from inspections, training, and feedback to improve the quality of care and implement new ideas. For example, leaders liaised with local GP practices and community nurses to ensure timely access to healthcare for people and worked with local activity services to increase opportunities for people to take part in outings and social events. Staff also engaged with advocacy services to support people in understanding their rights and making choices about their care. These partnerships helped ensure that people received joined up care and ensured the service could respond quickly to changes in people’s needs.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Staff and leaders demonstrated some understanding of how to make improvements, but the approach was not consistently applied or fully embedded across the service. Learning from incidents, audits, and feedback was sometimes recorded, but structured evaluation of outcomes and information on the impact was limited. For example, while some new systems were introduced for tracking medicine audits, care plan reviews, and accidents and incidents, these were often reactive and still in transition following the onsite inspection.

People, families, and care staff were occasionally involved in providing informal feedback, but formal mechanisms to engage them in improvement initiatives were limited. Staff reported they could raise concerns and suggest improvements, and leaders responded where possible. However, gaps in oversight, audit processes, and follow-up on action plans meant that learning was not consistently translated into service-wide change.

Although some external partnerships supported improvements, and leaders encouraged reflection and problem-solving, there was limited evidence of a clear strategy for developing staff skills around innovation or consistently embedding evidence-based practice.

While there were examples of positive change, the service needed to strengthen systems, oversight, and staff involvement to ensure learning and innovation were systematic and sustained.