Hafod Nursing Home

On this page

• 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 requires improvement. At this assessment the rating has remained 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 service was in breach of 1 legal regulation in relation to governance at the service.

This service scored 54 (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. They did not always understand the challenges and the needs of people and their communities.

In their failure to take consistent, timely action in response to risks and concerns, the provider had not prioritised safe and high-quality care or the promotion of a culture focused on learning and improvement.

Staff meetings, supervisions and spot checks had improved and identified where additional staff support was required to help drive improvements in the service. However, for some staff we spoke with we continued to find that their understanding of and ability to describe to us their learning from training was hampered due to the language barriers. This meant we could not be assured to the current training met the needs of all staff.

Reviews of people’s care plans had not ensured a fully inclusive and collaborative process of care plan development.

The provider had made improvements in relation to the staff training to better reflect people’s individual needs and so further promote equality and diversity.

Risk assessment and care planning processes although overall reflected and acknowledged people’s diverse needs would benefit from further development.

The registered manager did welcome and support an open culture which was supported by staff feedback to us. Most staff told us they were confident in recognising what a closed culture looked like and if they witnessed poor practice and reported this, they felt it would be acted on by management. People and relatives told us overall staff were kind and compassionate.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered manager was present within the service, leading by example and promoting inclusive behaviours. During our assessment the registered manager engaged with the onsite visits and feedback and responded to our requests for information. The registered manager and provider were receptive, overall, to our feedback and took some steps to immediately improve shortfalls which we identified during the assessment.

Any actions identified from the audits completed were added to the providers action plan however, we found some required actions affecting the safety of people continued to not always be completed in a timely way.

The nominated individual told us they visited the service each week to carry out an audit which included speaking with people using the service and staff. A nominated individual is appointed by the provider to supervise the management of the regulated activity provided by the service.

The provider had also engaged with a consultancy service who commenced in March 2025 who carried out monthly support visits. The registered manager used the feedback and findings of the consultants visits to implement the required changes and drive improvements in the service. This meant that the oversight of the issues and priorities for the quality and safety of people’s care had been improved. This demonstrated how the provider ensured the management team had appropriate skills, knowledge and support to manage the service with effective systems and processes.

The registered manager had completed supervisions with staff. These demonstrated staff had the necessary skills and knowledge and were competent in their roles and had the opportunity to identify any additional support or development needs they may have.

People and their relatives did know who the registered manager was.

People and relatives spoke positively about the management team they told us were caring and approachable.

Staff told us they felt supported and valued by the management team and understood their roles and responsibilities.

People did not always feel they could speak up and that their voice would be heard.

The providers approach in gathering feedback from people to give them the opportunity to share any concerns they may have was inclusive. However, 4 relatives reported this could be improved.

Some staff could not tell us what whistleblowing meant. It was difficult to understand if this was due to the lack of robust training or how the training was delivered as some staff members first language was not in the format of which the training was delivered. Although inspectors rephrased the questions, at least 2 staff struggled to provide suitable responses. This meant the provider had failed to ensure their related training was delivered effectively providing staff with the knowledge and understanding of their responsibilities to speak up should they need to do so. In addition, the providers whistleblowing policy did not include who staff could contact to raise concerns such as CQC or the local authority.

Staff told us they could raise concerns with the registered manager at any time. One staff member told us, “[Name] registered manager is a person you can go to if you don’t understand something. Her door is always open.”

People and relatives told us they could raise any concerns they had. The provide had a system of how to manage compliments and complaints demonstrating such concerns were actioned in a timely way. We saw that both positive and negative feedback was cascaded to the staff team to help drive improvements within the service.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Although records demonstrated that staff received training to enable them to adequately and safely fulfil to their roles the format in which this was delivered was not always effective.

We saw that staff had received equality and diversity training, and a process was now in place to assess staff knowledge and skills following this learning and how they applied this in the service. The registered manager told us that if staff required additional support with learning, they would facilitate this. However, we found there were some shortfalls in staff members ability to describe their learning and understanding of certain key topics. We saw and were told there had been some consideration and adjustments made to how staff training was delivered, which was mostly on-line but also included some face-to-face sessions in recent weeks. The staff member who carried out competency assessments told us this was to help meet the staff members diverse needs and bridge language barriers. Our findings demonstrated this still required time to be embedded and demonstrate it was effective.

The processes for staff recruitment, induction, training and on-going monitoring had improved since our last assessment.

Staff told us there were happy working for the provider and many staff had been in the service for several years.

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 provider had processes and systems for the monitoring of the quality of care provided to drive improvements. However, we could not be assured that these were effective due to the shortfalls we identified in the quality of the service. This included a quality assurance system and processes to support the registered manager in identifying the on-going concerns however, they did not identify all of the concerns we found. For example, we found inaccurate and unclear information in some people's care plans and risk management plans; management of risks was not well planned; hazards in the care environment and required improvements to keep people safe from harm were not actioned in a timely way; inconsistent recording in relation to identifying people’s assessed fluid intake and repositioning checks. That meant opportunities to drive forward improvement to benefit people had sometimes been missed.

Potential risks within the care environment, including the condition and cleanliness of the care equipment in use, were still not consistently detected or controlled. This meant people, staff and visitors were exposed to increased risk of harm. Although audits and checks were carried out, these did not identify the condition of some pressure cushions; shower chairs or shower drain holes. Staff were able to tell us what actions they would take if they found faulty or damaged equipment. However, our findings demonstrated the reporting of such issues was not consistent. There was a maintenance book for staff to record any required repairs in; however, this did not include the issues we found during our assessment.

We saw that the provider had a selection of environmental risk assessments however, they had failed to plan for the predicted heat wave although information had been shared by the local authority. There was no risk assessment or action plan in place to ensure the safety of people and staff. The registered manager actioned this after we requested a copy. We were told by the registered manager that there were only 2 fans in the building and lounge areas and prescribed medicine store areas were above the recommended temperature. The registered manager ordered a portable air cooler and implemented a risk assessment after we brought this to their attention.

Audits of the medicines were carried out by a staff member which were reviewed by the registered manager.

The provider carried out robust staff recruitment and we found safe recruitment was adhered. However, the staff files needed organisation to facilitate better oversight and auditing of this information. In addition, systems to assess the effectiveness of staff training although had been improved there was still further improvement required in making sure staff were learning from and understood their training. This will further allow the provider to assure themselves their staff were skilled and had the necessary knowledge to undertake their job roles.

The providers safeguarding processes to identify when people were at risks of abuse were robust. Where safeguarding concerns had been identified, the correct actions were taken, and concerns were reported to the appropriate authorities.

We found the provider was meeting the Accessible Information Standard (AIS). The AIS is a framework put in place from August 2016 making it a legal requirement to for all providers to ensure people with a disability, sensory impairment or those who required information in another format such as preferred choice of language or large print was provided to comply with AIS.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Staff told us they could make referrals to health and social care professionals via the management or nursing team. Relatives we spoke with, and the provider confirmed relevant health and social care professionals were involved with people’s care.

We received feedback from health and social care professionals we contacted as part of the assessment process. Whilst they acknowledged there was room for improvement from the provider, the health professionals were committed to improving outcomes for people living at the service and working with the management team to achieve this.

One health professional reported to us that staff knowledge and awareness of complex dementia that more collaborative working with specific health professionals and enhanced training would improve outcomes for people. Also, the well-being of people could be improved in providing timely support to provide suitable seating as recommended. They reported that when recommendations for specific equipment had been made these had not been actioned in a timely way. They told us that this meant people were supported in bed rather than being able to sit out in the communal areas or their bedroom for much longer than would have been necessary.The registered manager told us that decision not to purchase a piece of specialised equipment for 1 person as recommended had been made following further consultation with the GP and NoK.

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.

Shortfalls in the quality and safety of people’s care continued to be found at this assessment. At this assessment, and over the course of our previous inspections of the service, we have identified significant concerns in the safety and quality of people’s care, several of which represent repeated failings. There had been a lack of robust systems and processes for assessing and monitoring the safety and quality of people’s care. Our assessment identified that although improvements had been made there continued to be 3 breaches of regulations relating to the provision of, safe care and risk management, safety of the environment and good governance. We found enough improvement had been made in relation to staffing and they were no longer in breach of this regulation.

The provider continued to fail to fully meet their legal requirements and demonstrate a commitment to drive the improvements in people’s care.

Although monthly evaluations of care plans were taking place these were not entirely robust in identifying where changes in support plans and risk assessments were required.

The provider supported some people with complex dementia and associated distressed behaviours. Care records and training to meet the needs of people had been improved so they better reflected current best practice guidance. Analysis of the cause of distress and anxiety, incidents and accidents including what worked well in the reduction of such distress or what the triggers were, took place. This meant they could recognise and take timely actions to significantly improve the lives of people they supported. They had made some improvements to promote people’s independence to ensure they enjoyed a full and meaningful life, but this still required some further development particularly in relation to having access to the external areas.