Hardwick Dene

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 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.

The service was in breach of legal regulation in relation to people’s safe care and treatment and the ways people’s medicines were managed safely.

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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The service did not consistently demonstrate an effective learning culture. Records showed some incidents had not been reviewed by the management team in line with the provider's accident and incident management policy.Evidence of management oversight, follow-up action and consideration of lessons learned following incidents was not consistently demonstrated.

Although incidents and accidents were recorded, these were not consistently reviewed to identify trends, share learning or improve practice. This reduced assurance that opportunities to learn from safety events were consistently recognised and used to improve people's safety.

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.

People were supported to access healthcare services when required. Staff worked with healthcare professionals and shared relevant information to support people's ongoing care and treatment. We saw information was appropriately prepared and shared when people attended hospital to support continuity of care.

The provider completed pre-admission assessments to help ensure people's needs could be met safely. These arrangements provided assurance that information was shared appropriately with relevant professionals to support safe transitions between services.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidableharmand neglect. The provider did not always share concerns quickly and appropriately.

Concerns were not always recognised, escalated or managed appropriately in practice. We identified incidents involving potential harm where records did not demonstrate appropriate escalation, management review or follow-up. This reduced assurance that concerns affecting people's safety would always be identified and responded to in a timely manner.

Staff understood safeguarding procedures and were able to explain how concerns should be reported. Safeguarding information was available within the service and staff demonstrated awareness of their responsibilities. Staff demonstrated an understanding of the Deprivation of Liberty Safeguards (DoLS). The provider maintained oversight of DoLS applications, and records showed these were appropriately monitored and up to date.
 

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.

Risks to people's health, safety and wellbeing were not always effectively assessed and managed. Staff described a known falls risk relating to one person regularly attempting to avoid equipment intended to reduce the risk of falls. However, this information had not been reflected in care planning or risk management documentation.

We also identified care records which did not accurately reflect people's falls history. This reduced assurance that staff had access to complete and accurate information to support people safely.

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.

Equipment intended to support people's safety was not always maintained effectively. During the inspection, we found equipment used to enable a person to summon assistance and alert staff to movement was not functioning as intended. The person told us they were unable to summon assistance when required. This reduced assurance that equipment intended to promote people's safety was routinely checked, maintained and repaired promptly.

Leaders acknowledged that improvements to the environment were required. They described ongoing work and planned improvements to enhance the safety and suitability of the service. While this demonstrated that the provider had recognised the concerns, these improvements had not been fully implemented or embedded at the time of the inspection.

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.

There were sufficient numbers of staff to meet people's needs. Staff received training relevant to their roles and told us they felt supported by managers. Training, supervision and appraisal records demonstrated staff were provided with opportunities to develop and maintain their knowledge and skills.

Recruitment records contained the required pre-employment checks. These included references, employment history checks and Disclosure and Barring Service (DBS) checks. Staff spoke positively about the support they received from the management team and told us managers were approachable and available when needed.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean and we observed appropriate infection prevention and control practices being followed. Staff had access to personal protective equipment and suitable hand hygiene facilities.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Medicines were not always safely stored, we found nutritional feeds in an unlocked drawer in reception area and a steroid based cream in an unlocked cupboard within a person’s bathroom, they were not currently prescribed this cream, it had been supplied in December 2025.

Temperatures were reaching 29 degrees where medicines were stored for several days and although the provider tried to mitigate the risks by moving the trolleys containing medicines, the air conditioning unit was not working properly to maintain the recommended storage temperatures for medicines.

Medicines administration was being recorded on paper-based records (MAR charts). People’s allergies were clearly documented. However, some medicines that needed to be given at a separate time were being administered at the same time as other medication.

Some of the paper-based MAR charts had been handwritten, these were not signed or checked by two staff as per policy. One person had been administered their medicines incorrectly, one weekly administration from the handwritten MAR chart and the other from a printed version supplied by the local pharmacy. This person had been administered two bisphosphonates rather than just one for the last month (4 doses). Bisphosphonates are used to protect people’s bones; by giving it twice there is an increased risk of side effects.

We saw people treated with care and dignity when administering medicines and staff ensured that peoples’ privacy was maintained when administering medicines if they were in a shared area within the home. The information within the care folder about how people like to take their medicines was not always up to date.

Controlled drugs were stored, recorded and checked appropriately. Although the templates used to record the administration of controlled drug patches were incorrect. The record template was for a patch prescribed for dementia which needs changing every day when in fact the analgesic patch only needs to be changed once a week. This was confusing and could lead to other health care professionals believing a different type of patch was being administered. There was no evidence that the weekly pain relief patches were being checked every day to ensure that they remained in place.

Most of the equipment used to administer medicines were sterilised and cleaned before being reused however we were not assured that aero chamber devices that were used to help people with their inhalers were regularly cleaned. Topical medicines such as creams and ointments were not recorded as applied consistently in line with the directions for administration.

There were not always protocols in place to give staff guidance as when it would be appropriate to administer ‘when required’ (PRN) medicines. For example, one person had been prescribed a sedative for use when they became very agitated in a very specific circumstance. This was not written in a protocol or on the MAR chart and therefore the risk would be it was given inappropriately to sedate this person. Times of administration were not recorded for when PRN medicines were given. There was no guidance for staff about when to give someone morphine liquid, and they also had morphine injection prescribed which was no longer appropriate.

Care plans were in place for medicines but lacked detail. For example, we saw that staff were measuring oxygen saturation levels (SATS) for one person but there was no care plan in place for the management of their COPD (chronic obstructive pulmonary disease) and no information to tell staff what the personalised target range for their oxygen levels would be and what action to take if it was outside this range.

In another case where someone had been prescribed ‘just in case’ medicines for use at the end of life, there was no care plan in place that mentioned these, there was no plan for the management of a critical medicine for epilepsy when they were unable to swallow and currently the staff were struggling to administer oral medicines to this person. We also saw that blanket entries were added to their daily notes that were incorrect such as meal being served in the lounge when this person was not eating and remained in their bedroom. The liquids that were being served to them should be thickened to prevent choking but from an entry in the daily record where there was an entry regarding a cup of coffee this was not being done.

Communications sent from the GP surgery on email with instructions about people’s medicines were not loaded into the electronic care system, so it was difficult to check why certain actions had taken place.

Medicine incidents were being reported, people were informed and appropriate actions were taken.

Staff had completed medication training and had competency assessments in place.

An annual audit visit from the external supplying pharmacy had taken place in December 2025 where it had previously been highlighted around ensuring there were two signatures for any alterations to MAR charts.