Hartford Court

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

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 the regulations in relation to safe staffing and safe care and treatment.

This service scored 53 (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. Lessons were not always learnt to continually identify and embed good practice.

There was an inconsistent approach to learning from incidents. Although we saw learning outcomes being identified in investigations, this was not always acted on, implemented or embedded into practice, to reduce the risk of recurrence. However, we also saw examples where learning was shared and discussed. For example, staff meeting minutes showed the falls policy and procedure was refreshed with staff following people having multiple falls.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. When a person was admitted to the home, processes were not robust which meant specialist equipment was not in place on admission. Processes did not identify or consider environmental factors preventing the person from fully accessing communal areas. Learning outcomes from the provider’s investigation into the discharge included ensuring clear discharge plans confirmation of specialist equipment be fully completed before admissions.

The provider did not always identify or share safeguarding concerns quickly and appropriately.

We saw evidence safeguarding concerns were investigated and actions taken to reduce risk of recurrence. However, poor recording and oversight of care notes and incident reports meant concerns were not always identified, acted on or reported in a timely way. The registered manager told us they would be completing a review of records to identify and report any outstanding concerns.

We received feedback from partners that the registered manager was engaging with the local authority to address and learn from safeguarding investigations.

When people were deprived of their liberty, the provider made applications to the local authority as required.

The provider did not always work well with people to manage risks. Care plans and risk assessments were not always updated when people’s needs changed, and information was sometimes inconsistent and conflicting. For example, when people were at risk of falls. This meant staff did not have clear guidance on how to support people safely. The provider had an action plan and was in the process of reviewing all risk assessments and care plans to ensure information was accurate and staff had clear guidance to support people safely.

Kitchen staff demonstrated a robust understanding of how to prepare food safely for people who were at risk of choking and needed the texture of their food modified. We observed people were supported with meals in line with their assessed needs.

The provider detected and controlled potential risks in the care environment. The provider assessed environmental risks such as risk of fire and legionella. Records showed environmental checks were completed, and moving and handling equipment was serviced and maintained as required.

Fire safety equipment was in place and serviced as required. Evacuation plans were visible, robust and clear.

The provider did not make sure there were enough qualified, skilled and experienced staff.

Most people and relatives we spoke with told us they felt there wasn’t enough staff. Feedback included comments that staff were lovely and kind but always rushing because they were too busy, didn’t have enough time, that there were long waits for support after using call bells, and people often had to wait for long periods of time for personal care or breakfast.

Staff also shared concerns about staffing levels. An investigation completed by the provider also identified staffing pressures as a contributing factor to the incident being investigated. The provider’s staffing dependency tool was not used in a person-centred way, did not reflect people’s actual level of need and did not list all people currently living at the home. This meant although rotas showed staffing levels were met in line with the dependency tool, we were not assured the calculated number of staff on shift was sufficient. The provider told us they would be rolling out a new staffing dependency tool, but this was not yet in use.

The provider followed safe recruitment processes, in line with legal requirements.

The provider assessed and managed the risk of infection. The home appeared clean and there were no malodours. Staff had access to PPE and this was stored appropriately. Cleaning products were available and stored securely.

People told us, “It’s spotlessly clean” and “The cleanliness is good”.

The provider did not always make sure medicines were managed safely. An external audit completed in January 2026 identified multiple and significant concerns with medicines management. At the time of our inspection, the service had addressed many of the immediate concerns identified by the audit but was still in the process of strengthening medicines management processes. For example, ensuring medicines given covertly were prepared and administered safely and introducing more robust monitoring processes for people at risk of constipation. These improvements still needed time to embed. When people were prescribed ‘when required’ (PRN) medicines, protocols were not person-centred. The service was in the process of reviewing and updating all PRN protocols to ensure they were person-centred and contained enough detail to support people safely.