Archived: Harmony House

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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. This is the first assessment for this newly registered-service where a rating has been awarded. At the February 2024 assessment under the previous legal entity, we found some issues although there was not enough quality statements assessed so we could not rate. At this assessment this key question has been rated inadequate.

Inadequate: This meant people were not safe and were at risk of avoidable harm. There was an increased risk that people could be harmed. The service was in breach of legal regulations in relation to safe care and treatment and safe and effective staffing.

This service scored 38 (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 concerns. Lessons were not always learnt to continually identify and embed good practice.

Staff told us they reported any accidents and incidents when things had gone wrong. However, most staff told us they did not have any information about lessons learnt or why things had happened. One staff member told us any lessons learned would be shared at shift handover or staff meetings but was not able to give us examples of any learning shared in 2025. The staff member told us, “I am not sure, there’s possibly one or two this year. One resident [person] had a fall in the bathroom. Some changes were made for them. We now assist them more and they let us do more for now.”

In some cases, we found lessons had not always been identified, and measures to reduce risks, had not always been clearly recorded. For example, a medicines error analysis completed in June 2025 may not be accurate. We found errors for 1 person missing their medicines was not included in this analysis. This meant a true picture of medicine errors had not been made which meant people continued to be placed at risk of avoidable harm. Staff confirmed adverse incidents were shared in daily meetings and handovers between shifts, but they lacked detail about the actual reasons why something happened and how to prevent it from happening again.

The area manager explained the changes they had made since the previous inspection. One action was to set up ‘You said, we did’. This was a board that displayed the feedback the home had received and what the provider had done to improve. The area manager told us they had improved their quality assurance and checks, and additional support had been given to the new management to improve people’s outcomes. When we discussed some of the concerns we found at this visit, the management team responded quickly to make improvements. Not everyone we spoke with was convinced improvements had made things better for them.

The provider did not always work 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.

A staff member told us they would send key information, such as a person’s medicine administration forms, respect form, catheter passport and details of their physical needs if a person transferred to another care organisation. They told us. “Their medicines and PEG feed (tube directly into stomach) also goes with them. Night staff will know this, too.” However, one staff member told us they were not sure what information would have to go with the person to hospital. We also identified concerns in relation to the accuracy of recording of administration of people’s medicines at this inspection. This increased the risk people will not be transferred to other health providers with an accurate record of care, which may increase risks to their physical safety and well-being. We did see care records which showed staff worked with the GP, tissue viability nurses and speech and language therapists to monitor people’s health needs.

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, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

People felt safe with the staff who cared for them. One person told us, “The staff are pleasant here. They check on me regularly and ask what I need. I’m a lot safer here.” Another person said, “The staff are fabulous. They talk to me nicely. We have a laugh and a joke. I’m not worried about them.” Relatives spoke highly of the staff and said they were good at caring for their family members. Relatives said they had no concerns about their family member not being safe and were positive about how their family members were treated. Some staff knew what to do to protect people from poor practice, whilst others we spoke with did not. All staff spoken with knew to report to a concern to the manager, but some staff were not clear who other than the manager, who they could refer concerns to, such as CQC, Police or local authority safeguard teams. This was important to understand their role in the absence of any manager. We found nurses were commencing investigations of their own before handing information over to the management staff which potentially impacted the safeguarding investigation process. One nurse told us, “I would speak to the member of staff and get as much information as I can. Ask why they behaved that way and definitely report it to management.”

The provider did not 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 the last visit we found risks to people went unnoticed, such as limited risks identified in people’s care records and people having access to products that if ingested, could cause harm because some doors were left unlocked. At this visit we found some improvements and some rooms that contained potentially harmful products or risks were locked. However, on the first day of our visit we found an unlocked room off a communal lounge contained a significant number of tablet and liquid medicines ready for disposal. The manager told us those medicines were to be returned for destruction. No staff had made sure, the room was locked to protect people, or, challenged us to see what we were doing. During our visit, the area manager arranged for their safe disposal. In other communal rooms, we found nail polish remover, 2 unopened sterile sodium chloride 0.9% irrigation solutions, about 1.5 litres of PVA glue and 2 bottles of alcohol which were left out. This had the potential to put people at risk if they were used in a way they were not meant for. The manager told us they completed a daily walk around of the premises, but these issues had not been identified. When we returned 6 days later, these products remained accessible to people and had not been identified as an issue.

An area for improvement we found was staff decanting cleaning products into smaller and manageable bottles. On the second day of our visit, a housekeeper used a different cleaning agent than what was written on the bottle. This meant if ingested, or it came into contact with eyes or skin, the measures to treat that area may not be the right one. We told the manager to ensure measures were taken to stop this from happening again.

Staff told us when new people were admitted to the home, care plans were not always completed promptly, which increased the risk that people may not receive care safely. We checked and found that a person who was admitted on 30 July 2025 did not have important risk assessments and care plans in place to manage their individual health needs until 5 days later. This was because they had not been completed. This put this person at risk of receiving support that may not be safe for them.

Staff told us they had completed fire safety training. However, staff were unaware of what arrangements were in place should the home need to be fully evacuated. One staff member told us, “I didn’t get proper training on the evacuation plan and things. They will tell us what to do when we evacuate, I don’t know anything more.”

There were inconsistencies in the numbering of people’s bedroom doors, which may lead to delay and increased risks in identifying where fires broke out, should fire occur. For example, one door number checked did not correlate with the number on the fire door register. We asked the registered manager to address this. We asked one staff member what would happen in the event of a fire. The staff member told us, “We [staff] would all go down to the fire panel and check which zone and check which room. I'm not sure about rechecking [fire] door numbers, you would need to be fire trained. I'm not sure if anyone fire trained is on [shift].” Another staff member told us they were a fire marshal. They advised us what they would do in the event of a fire including liaison with senior staff. The staff member told us for any specific information about how to support people to evacuate they would check people's care plans. They were not aware of PEEPs, [personal evacuation plans], which would allow them to quickly understand what support people required in emergency situations. Staff told us they had completed fire safety training. However, staff were unaware of what arrangements were in place should the home need to be fully evacuated.

The provider did not 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 our last inspection we found some environment risks put people at unnecessary risk of harm because storerooms containing harmful products were left unlocked. At this visit we found 1 door identified to be locked was not which was a room off a communal lounge. We checked that room and found it contained in excess of 6 boxes of medicines that were due for return and disposal. The room had a lock on the door, but the lock had not been engaged so anyone could access those medicines. We saw other risks already mentioned had not been identified on the managers walkaround which was meant to make sure the environment was safe.

Overall, people felt safe in the home. However, one person told us the shower room they used “floods” each time they had a shower making it slippery. This person told us it had been reported but there was no change. We spoke with a maintenance person who said the issue was the length of time the pump was in use to take away the water into the drain as it was on a timer. There was no action taken to see if there were alternative options instead of the person taking less time to shower as was suggested to us. Therefore, the shower room continued to be at risk of water backing up, causing a slip hazard.

We asked staff how they knew equipment was safe to use, one told us, “We do check it before we use it,” demonstrating staff were aware of the importance of this to keep people safe. There were limited numbers of hoists available to support people in the home. Most people were cared for in bed and we were told most people in the home needed the support of a hoist. Whilst action had been taken to ensure people had their own slings to use with the hoist, one person’s sling had gone missing. This meant they were unable to be hoisted to support their needs, however we found boxes of new slings were in store. Not all staff knew this.

The provider did not make sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They did not always work well together to provide safe care that met people’s individual needs.

The majority of people and relatives felt there were not enough staff to meet their needs. We were given examples of how staffing levels had negatively impacted on them. One person said, “I need 2 people to get me out of bed. There’s just not enough staff, so I don’t get out of bed. If I did need to get out of bed, I need a wheelchair and there’s never enough of them as everyone else needs them. I just stay in bed, it’s not worth asking for 1. I can’t weight bear, so I’m just trapped in my bed.” Another person said, “They get me whatever I want, but not straight away. They answer the buzzer eventually; it depends on how busy they are. I only use it when I really need it. I’m in bed all of the time.” A third person said, “They (staff) answer my buzzer sometimes, but if they are helping others no one comes until they have finished and that can be a while.” During our visit, our observations early morning showed staff were busy supporting people and that people’s care was more task based than responsive to people’s needs. We heard one person shouting out for help, yet we saw no staff respond to their many requests for help. One relative said they wanted their family member to spend time out of their room, but this was not always possible. They said staff were busy and if their family member wanted to go to an activity, staff may not always have time to get them out of bed and transferred downstairs.

There were mixed views from staff in relation to the numbers of staff available to support people. One staff member said, “You can be a little bit run ragged. I feel [care] staff are a little stretched and don’t have much time with the residents, [people].” The staff member told us there were occasions where they were asked to take on additional responsibilities, which took them away from their main area of work. This did not support them to deliver their primary role, and the staff member told us they spent additional time at the home without pay to reduce the impact on their main area of work. Another staff member told us, “It can be hard. We have had some new staff, but some don't have experience and we're having to show them. It can be [at any time], including at weekends. It has been raised. It does not feel shifts are equitable and changes can happen at short notice.” Nursing staff told us they didn’t feel there was always enough staff and didn’t always feel supported in their roles. They felt the dependency tool used was not reflective of people’s needs to give an accurate figure in terms of the staff numbers required. We noted that nurses were also writing care plans which took them away from their other nursing duties. A nurse told us they regularly worked beyond their shift to complete their duties and ensure people were safe.

The manager told us they used 2 different evaluating tools that assessed people’s dependency. We found those tools scored people’s risks into care hours differently. The manager told us they staffed according to the system that scored the lowest risk levels, despite their other system showing people may need more care hours per day. This meant we could not be confident staffing levels met people’s needs. This meant the provider was in breach of regulations for staffing.

Staff told us they were subject to recruitment checks which included references and a criminal record check before they started. This helped ensure staff were of suitable character to care for people.

The provider had not always assessed and managed the risk of infection. The provider detected and controlled some risks and shared concerns with appropriate agencies promptly.

We saw some positive practices to minimise cross infection. Handwashing signage was displayed in some toilet/bathroom areas and personal protective equipment (PPE) stations were near bathrooms and were stocked. Staff were seen to use the appropriate PPE at the required times. There were enough transfer slings to ensure people had their own sling to minimise the risk of cross infection when they needed to be transferred. However, 1 staff member told us some people used to have a toilet sling but they were no longer used. People were given a standard sling which meant implications for staff maintaining hygiene, especially when staff felt there was not enough slings in the home. A housekeeper told us they cleaned all the rooms on each floor. The housekeeper knew when to use separate mops and buckets for different areas of the home. During our visit, there was a situation that required increased cleaning regimes to keep people and staff protected. We did see cleaning products being used, but on our second day, this was decanted into a wrongly named bottle. This could cause confusion when cleaning some areas with specific cleaning products.

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

Improvements were required in the way people’s medicines were administered and recorded. The medication administration system was reliant on having an internet signal to review people’s medicines. During our first day, there was no signal to enable us to access people’s medicines records to ensure people were safe. During our first day we found a significant number of boxes contained returned tablet and liquid medicines for people, which were in an unlocked room and had not been included on a register for safe destruction. The area manager took action to remove those medicines during our visit. We saw from some records that some people did not have their medicines given to them as per their prescription. For example, 1 person required time critical medicines to be given at set times being 11am, 3pm and 7pm. We found this person’s medicines were not always administered at these times. We were not confident this person received their medicines as required. We found the management of covert medicines (medicines disguised in food and fluids) was not clear.

The system for nurses to escalate medicines errors on the system was not sufficient. One nurse said they had to make written notes to give to the manager because they could not record them on the electronic system. This could cause a delay in ensuring those staff administering medicines had up to date information. The manager completed medicine audits to ensure medicines were administered safely. We looked at 2 July 2025 medicine audit which recorded a score of over 95%. However, the issues we found regarding stock returns and time critical medicines not being given in line with the prescription had not been identified. Following our feedback on day 1, the manager told us they completed an investigation, but they had only looked at 1 day and had not looked at all of the person’s time critical medicines over the medicine cycle where there were more concerns.

Staff did not consistently ensure medicines administered by them had been taken by the person for whom it was prescribed. On the second? day of our visit, we saw half of a white tablet/sweet on the dining room floor. It was still on the floor 3.5 hours later, with staff stood by it. Although we could not be confident it was a medicine, a nurse thought it could have been one person’s medicine because records confirmed this person had their medicine in the dining room shortly before we found it on the floor. This increased the risk other people may consume medicines not intended for them. Risks to people were also increased because the systems in place to record people’s medicines administration were not working well. We could not always be sure what time people’s medicines were administered, if they had been missed, or if sufficient gap between medicines administration had elapsed before additional medicines were administered. Poor recording of medicines also increases risks to people when they transfer between care providers and may also mean people do not get access to pain relief promptly when required.

Staff were not allowed to administer people’s medicines unless they had been trained to do so. We asked one staff member about people’s access to medicines which may be needed occasionally for pain relief. The staff member told us, “I let the nurses know if people are in pain. You can rely on some of the nurses; some you have to keep reminding.”

Some people need to have their medicines covertly. We found best interest decision had been undertaken to inform such decisions, however, care plans and the provider’s electronic medicines systems lacked clear guidance for staff to follow to administer covert medicines safely. One persons care plan did not specify staff were required to crush 1 tablet mix with 1 spoon of porridge then repeat individually for each remaining medicines and no system to confirm that porridge only was used. We could not be confident people received their medicines safely and the provider was in breach of regulations.

We checked medicines prescribed “as required” which had protocols to guide staff how to use the electronic system. Where people had medicines via a patch, those medicines were administered safely and as per instructions.