Hafod Nursing Home

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 inadequate. At this assessment the rating has improved 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 2 legal regulation in relation to safe care and treatment due to inadequate care planning and risk assessment and environmental risks.

This service scored 56 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Since March 2025 the provider has worked with a consultant to improve the safety and learning culture within the service.Although the provider already had systems and tools in place, many of these had been changed in the months prior to our assessment, with the support and guidance of the consultant. However, they did not consistently identify the concerns we found during the assessment.We found some known risks to people continued to not be assessed and further information for staff was needed about how the risks would be managed. The system in place for consistent analysis of incidents needed to be embedded to assess its effectiveness ensuring there were no missed opportunities to drive improvements in the service from lessons learnt in relation to incidents which occurred. For example, there was no investigation or detailed analysis as to what led 1 person to frequently remove core equipment from their person. This meant there was a lack of understanding of how to reduce the risk of reoccurrence. There was a record of complaints and compliments which were received. These were analysed and shared with staff to support future learning and improvements. We found there were still some shortfalls in the consistent guidance for staff in relation to people's individual needs and risks which meant a proactive culture of safety was not always demonstrated. This meant opportunities for learning and improvements in people’s care were sometimes lost or delayed.

People and relatives told us they could contact the service if they had any concerns about their care. Most told us they had met or spoken with the registered manager and knew they were able to speak with them if they needed to. A relative told us, “I get regular calls from the manager to keep me up to date with what is happening.” However, another relative told us, “I would not say it was easy to get hold of the manager. More availability in that regards would be good.”

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

Systems were in place to ensure people’s needs were assessed prior to moving in. However, care records held by the provider required some improvements to demonstrate there was adequate information for robust continuity of care, including when people moved between different services. This included when people transferred to hospital due to their health conditions having deteriorated. Most staff we spoke with knew people and their support needs well.The providers audits and monthly care plan reviews had failed to identify some of the shortfalls in peoples care records we found during the assessment.This included the ensuring actions were clearly documented following analysis of incidents occurring.

Most relatives told us, overall, they felt informed and involved when their loved one was moving into the service and were kept up to date with changes verbally. We saw evidence and relatives told us that people were taken to hospital should they require this and were confident that their loved ones received additional healthcare in a timely way.

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 shared concerns quickly and appropriately.

The provider had a safeguarding policy in place and was aware of their responsibilities to keep people safe.

The registered manager recognised what safeguarding meant and had acted appropriately to potential abuse. Whilst investigations into these incidents had been carried out and appropriate safeguarding referrals to protect people from abuse had been made. The new analysis of safeguarding incidents needed to be embedded to monitor their effectiveness in making and sustaining improvements in the service. The service shared concerns appropriately with relevant agencies, teams and professionals and this was confirmed by the local safeguarding team.

Staff had received safeguarding training and told us if they had any concerns in relation to suspected or actual abuse they would speak to the nurse or registered manager. However, 1 staff member we spoke with found it difficult to understand and tell us what safeguarding people meant, this was due to language barriers. This meant we could not be assured all staff had the correct knowledge and skills to prevent or report avoidable harm to people.

Most relatives of people who lacked capacity to make their own decisions told us they had been involved with applications for Deprivation of Liberty Safeguards (DoLS) authorisations and meetings about decisions made in people’s best interests.

People told us they felt safe with the staff supporting them.

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.

At this assessment, we identified staff were not always provided with clear information and guidance on managing associated risks. Some known risks had not been assessed, so there was no guidance for staff about how these risks should be managed, which had the potential to put people at increased risk of harm. There was no information or mitigation in place to support a person who for several months had removed equipment from themselves, this increased the risks to the person.The registered manager took action to mitigate risks and update care records following this being brought to their attention.

We saw staff members supporting people with complex needs now had the opportunity to receive the relevant, in-depth training in people’s health conditions. There was evidence that such training had been followed up by the provider to assess staff’s understanding and learning. This meant they could now be assured staff had the appropriate skills and knowledge to support people safely.

Most relatives told us they were contacted by staff and management following incidents occurring or new risks emerging involving their loved ones. They told us they received information about changes to people’s support needs. However, some relatives felt communication about their loved ones and their involvement with planning care and managing risks could be improved. One relative told us, “I have certainly never been involved in care plan reviews.” Another relative told us, “I used to get regular monthly updates, but they stopped about a year ago. I have sent e-mails but have had no response so far.”

Most relatives told us they felt their loved ones known risks were well managed. One relative told us how they had been involved in a discussion around the use of bed rails to prevent their loved one from falling from bed. This has been an issue for this person prior to moving to Hafod Nursing Home.

We saw that risk assessments now reflected people’s rights under the Mental Capacity Act 2005 (MCA) and best interest decision-making took place to demonstrate decisions made on behalf of others were in their best interests. For example, when people refused medicines, we saw that meetings had taken place with family members, the GP and a nurse and it was agreed on these occasions medicines could be given covertly. This had been assessed in line with the person’s rights under the MCA to protect them from risk of serious harm.

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

At this assessment we had on-going concerns in relation to the increased risk of avoidable harm to people as a result of the provider’s failure to ensure the premises and care equipment were consistently safe, secure and properly maintained. For example, people remained at increased risk of trips and falls due to uneven surfaces, and cross infection due to covering on equipment and furnishings being worn and porous, preventing adequate cleaning. This was due to the provider failing to identify and/or act on safety concerns related to the premises and equipment in a timely way. We found there were still further improvements required to ensure the environment was consistently safe. This included ensuring the systems and tools used identified all areas of concern and that the provider took action in a timely way. We continued to find some shortfalls in safety which included the correct opening of widows which had restrictors in place, hard flooring which had holes in still had not been replaced although this had been identified back in September 2023. The registered manager told us this was scheduled to be replaced in July 2025. The garden, although fencing had been put in place to restrict access this still required work to ensure it was safe and accessible to all people wishing and able to access the garden independently. The paving still posed a trip hazard and risks to those living with dementia.

We also observed that the main kitchen had been left open and unattended for at least 9 minutes, despite there being a keypad lock to secure the door when the kitchen was left unattended. This meant people who were not able to maintain their own safety in a kitchen environment, where multiple hazards were present, were placed at risk of harm should they have entered this area during this period of time.

Call bells were found to be missing from bathrooms, the activity room and some people’s bedrooms during our time at the service. There was no risk assessment in place to mitigate the risks should an incident occur in these areas and staff require urgent assistance. The bathrooms with missing call bells had been identified by the registered manager in their January 2025 audit and noted on the service action plan. A quote had been received by the provider in April 2025. However no follow up actions had been taken at the time of our assessment. The registered manager told us, and we saw that staff had ‘walkie talkies’ which they used to communicate if help was needed.

The registered managers action plan also detailed that the passenger lifts both had faults identified following the service of these on 01 April 2025. In the 1 lift the communication button was ‘inoperative’ and the other the light worked ‘intermittently’. On the action plan these were both deemed to be low risk. However, a further ‘jobs to be completed’ action plan was provided to us and the risk rating had increased to medium with a completion date of 31 August 2025. The registered manager had contacted a company for a date for the repairs to be carried out after we raised this with them.

We found that some action had been taken to improve the safety of the environment since our last assessment which included a new auditing and monitoring system being implemented; control of hot water distribution temperatures had been addressed; access to hazardous items and areas due to unsecured doors were now restricted. Broken or missing radiator covers in both private rooms and communal areas had either been replaced or risk assessed.

People and relatives, we spoke with did not raise any concerns in relation to the environment being unsafe.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider ensured that staff had received appropriate training to meet peoples known health and support needs. They had improved how the training was delivered with more face-to-face training being completed and the staff members knowledge and skills were assessed following the completion of this training by carrying out observations.

Staff supervision had been completed and recorded. These meetings were used to help drive improvements in the service.

During our time at the service, we observed enough staff to support people as they needed.

The provider used a dependency tool to assess the level of staffing needed to meet the needs of the people using the service. The registered manager told us that if a person needed 1 to 1 support, they would increase staffing levels. Staff rota’s we were shown also demonstrated that there were enough staff to support people based upon the providers dependency tool used.

Most people and relatives told us they or their loved ones were normally supported by staff who knew them well and recognised risks. However, several relatives raised concerns about the number of staff and the different staff working at weekends. One relative told us, “Staffing levels are ok during the week, but you do see more agency staff at night or at the weekends and they seem more pushed for time.” Another relative told us, “You don’t see many regular staff, in fact, they are different most of the time. Certainly, less of them at the weekend. Staff might be able to interact more if there were more of them.”When we viewed the staff rota’s these demonstrated a consistent staff team with minimal agency staff used.

The providers recruitment systems were robust. The registered manager told us they had identified the need to restructure the staff files to ensure the information was more accessible. The registered manager told us this was detailed on the action plan.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

During our last assessment we observed multiple areas around the service where the flooring had holes where equipment had been removed or due to general wear and tear, we found the flooring in these areas still had not been replaced. The registered manager told us this was scheduled to be replaced in July 2025. We continued to find some pressure cushions were dirty; a shower chair was worn and had a broken seat; extractor fans in shower rooms were dirty; shower room drain holes had debris/dirty in them; legs of toilet seats were rusting and had a build-up of dirty water; around taps we saw a build-up of rust from the plug chain. This was not conducive to good IPC practices and the providers infection, prevention and control (IPC) audits had failed to identify these concerns.The registered manager took immediate action to address these shortfalls once they were brought to their attention.

However, we found that armchairs, dining chairs and foot stools had been replaced. Action had been taken to ensure continence aids, toiletries and prescribed creams were now stored safely to prevent cross contamination.

People and most relatives felt the service was clean and tidy and there had been improvements since our last assessment. One relative told us, “It’s nice to see it [the home] having a bit of a makeover recently. I hope they keep it up and do more.” Another relative told us, “The place seems cleaner and better maintained recently. There have been changes and decoration of communal rooms. It was rather overdue to be honest.”

All staff were observed to be following safe practices and were adhering to the safe disposal of personal protective equipment (PPE). This included gloves and aprons. The provider operated an effective system to ensure all staff were subject to spot checks to monitor the safe and correct use of PPE. Staff told us the PPE they needed to prevent and control the spread of infection was available to them. Staff had completed IPC training.

The provider made sure that medicines and treatments were safe and met people’s needs,capacities and preferences. Staff involved people in planning, including when changeshappened.

The provider had policies and procedures designed to ensure people’s medicines were safely managed. We found no concerns relating to the handling and administration of medicines. However, storage of medicines was not always safe.

On the first day of the assessment, we found that the temperature exceeded the safe maximum temperature in areas where prescribed medicines were stored. At this time there was no risk assessment in place or means of cooling to the room to the required temperature. The registered manager took immediate action when we brought this to their attention. They ordered an air cooler and carried out a risk assessment. The thermometer on the medicine’s fridge was faulty indicating that the temperature was much higher than the actual temperature inside the fridge. During the assessment the maintenance officer was asked to look at this problem, which was resolved.

At our last assessment topical medicines were not always stored safely. At this assessment we saw that people’s topical medicines were now always stored securely or clearly labelled, reducing the risk of ingestion, misuse and cross infection.

People’s support plans included the level of support they needed with medicines.

The information for staff members to follow for 'as required' (PRN) medicines, to ensure a consistent approach, was clear as to how, when or why to use such medicines. This meant staff knew when to give these medicines.

For people who were prescribed creams to treat skin conditions, we saw these medicines were included on the medication administration records (MARs) or body maps. They had instructions on when, where and how the creams should be applied. Where people were prescribed medicines to reduce the risk of blood clots, which increased the risk of excessive bleeding, risk assessments were in place. Where medicines were to be given covertly there was clear guidance for staff to follow. In addition, there were clear protocols and guidance on how to correctly and safely administer medicines to people who had this administered via a feeding tube.

People and relatives, we spoke with had no concerns in relation to the support people had with their medicines