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

We looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question requires improvement. At this inspection the rating for this key question has changed to inadequate. This meant people were not safe and were at risk of avoidable harm. We found a continued breaches of the legal regulations relating to relation to safe care and treatment, governance systems and premises and 1 new breach relating to staffing. Risks to people, including risks associated with their individual health needs, were not consistently assessed, monitored and mitigated. The service’s environment was not always clean, secure or properly maintained to ensure people, staff and visitors were safe from harm. Staff had not always been provided with clear guidance on how to safely meet people's individual needs and manage risks. Where people had known health conditions or allergies, these had not always been reflected in their support plans and risk assessments had not been developed to ensure risks were managed and staff were aware of such risks. We identified concerns in relation to infection prevention and control (IPC) standards and practices. We identified some concerns in relation to management of people’s medicines, including the handling and application of people’s topical medicines.

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.

Relatives told us they knew how to speak up if they had a concern about their loved one’s safety. Most people and their relatives told us they felt issues and concerns were addressed by the registered manager when brought to their attention. However, some relatives told us they felt overall communication with the service could be improved as they had difficulties in contacting the registered manager. Many relatives told us they were not involved in face to face care reviews and received updates about their loved ones’ care via e-mail, which they reported had decreased over recent months. One person told us they felt frustrated due to restrictions imposed upon them in relation to smoking and the impact this had on their independence. People and relatives told us about some of the positive changes within the service, for example where the corridors and lounge areas had been decorated.

Staff told us they had received training to help them manage risks associated with the care of people they supported. However, we found that some staff had not completed all of the provider’s mandatory or refresher training. Staff we spoke with did not always demonstrate their learning from the training they had received, for example in relation to moving and handling, Mental Capacity Act (MCA) 2005, best interest decisions and Deprivation of liberty Safeguard (DoLS). Some staff could not tell us about learning they had completed and what this meant for people using the service. Staff told us they could make suggestions to management in relation to people’s support needs and any changes to improve care. A staff member said, “[Name], the registered manager, has an open door. If I see that we could put things in place here to improve care and teamwork, I share with [name] registered manager.” The registered manager understood their duty of candour responsibilities. Staff told us there was a positive impact from lessons learnt which were discussed at staff meetings and supervision. This had included a review of the registration of agency nursing staff used at the service following an incident.

There was a system in place for the registered manager to review incidents and take learning from such events. However, we found the provider had failed to learn from shortfalls identified during previous inspections of the service and had not been proactive in taking actions to improve the safety of care and maintenance of the premises. The registered manager had reported environmental concerns to the provider, but we saw these had not always been acted upon. This included areas of the service where replacement flooring was required. The management team explained how they analysed information and used this to make positive changes within the service. However, we found improvement actions were not always effective or embedded to drive improvements. A lack of clear and consistent guidance for staff in relation to people's individual needs and risks 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. Where people were expressing physical or emotional distress, additional support from health professionals was sought.

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. However, some did not feel confident that people’s continued safety was managed and referrals to other health services were carried out in a timely way. One relative told us, “I have a problem in communication; the staff don’t keep me informed of [name’s] needs or any updates. When [name] went into hospital, they were contacting me to find out how they were getting on rather than staff telling me.” Another relative told us, “It’s not really the right place for [name] due to their age. They never take [name] out, but we do sometimes. My concern is [name] is totally confined; they don’t have the staff to give more time."

The management team told us how 1 person had a delayed hospital admission due to an agency nurse who did not have the knowledge and skills and appropriate information to guide them on when to access further medical support. Further shortfalls we found in guidance for staff to follow in relation to changes in people’s health conditions and when to contact healthcare professionals were shared with the registered manager who told us they would address these areas where information was missing in the support plans. The registered manager and nursing team told us how they worked closely with other health professionals and had tried to develop strong working relationships to improve the service for people. Staff told us they felt supported and had all the information they needed to support new people moving into the service. Although staff told us and we observed how they supported people appropriately, at times the provider used agency staff to support people living at Hafod Nursing Home who did not know people well and the lack of guidance increased the risks to people.

There were no concerns raised by commissioners in relation to the admissions or discharges within the service. A health professional told us they had no concerns in relation to the service.

Processes did not always ensure staff supporting people had clear guidance on, and awareness of, their individual needs and risks to keep people safe. Records we reviewed demonstrated the provider assessed people’s needs prior to providing care. However, support plans lacked key information and guidance for staff on known risks to the person, including risks associated with people’s health needs. This increased the risk of people receiving unsafe care, and a clear awareness of risks not being maintained across their care journey. We found no evidence this had caused harm to anyone. However, the lack of key information and robust support plans placed people at an increased risk of inappropriate care and unmet needs should this information need to be shared with other agencies. Reviews of people’s needs and support plans were not robust or inclusive. The registered manager took on board the need to make this process more inclusive and robust.

People and relatives told us they understood how to raise any safety, or abuse concerns they may have. People we spoke with told us they felt safe and supported. Most relatives we spoke with told us they felt, overall, their loved ones were safe being supported by staff and did not have concerns about their safety. One relative told us, “They [care staff] seem to be on top of everything. I think he is safe. He came back from hospital without his slippers and walking stick, they sorted it straight away.” However, another relative had some concerns in relation to safeguarding and told us, “[Name] had bruises on her ankles and to her side which hadn’t been reported. They [management] said it was the bed guard.” Records we reviewed indicated that bed rails had now been removed due to this known risk.

Staff told us they had received safeguarding training and could describe circumstances which would lead to them following the service’s safeguarding policy and procedure. However, we found not all staff could tell us what safeguarding meant or how they would raise these concerns, other than speaking with the registered manager. This placed people at increased risk of harm. The registered manager had not identified this shortfall in the effectiveness of safeguarding training and told us they would provide additional training to improve staff knowledge. The registered manager and clinical lead investigated and shared safeguarding concerns with the local authority’s safeguarding team when they were identified. Most staff we spoke with were aware of the service’s whistleblowing policy.

We saw that most staff followed agreed safe processes associated with supporting people with complex needs. For example, we saw staff supporting 2 people who were expressing emotional distress or pain, in such a way to reduce the risk of harm to themselves and others. However, we observed multiple aspects of the service’s physical environment and care equipment which placed people at increased risk of avoidable harm. These risks included trip hazards, burn/scald risks, unsecured doors to areas of high risk, fire safety risks and infection prevention and control (IPC) concerns. Some of these areas of concern had not been identified by the registered manager but those which had, had been escalated to the provider, who had failed to take timely action to address these. During the assessment, we saw some positive examples of staff demonstrating how they supported people safely.

Systems and processes to protect people from abuse and neglect were not always effective, which increased the risk of immediate action not being taken in response to safeguarding concerns. This was a particular concern 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 were placed 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. The provider had a safeguarding policy in place and was aware of their responsibilities to keep people safe. They had processes in place for recording safeguarding incidents and outcomes and actions from these. There were on-going investigations in relation to staff members’ conduct and the registered manager was liaising with the appropriate authorities in relation to these matters.

Some 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, but this had been less consistent recently. Some relatives of people who lacked capacity to make their own decisions told us they had been involved with applications for DoLS authorisations and meetings about decisions made in people’s best interests. However, we saw that risk assessments did not always fully reflect people’s rights under the MCA. This meant the person was at increased risk of having restrictions in place which may not be the least restrictive option. For example, 2 people who smoked were not permitted to keep their lighters themselves. There was no clearly documented evidence as to why this decision had been made, based upon risks this may pose. For people who lacked capacity and had pressure alarms in place there was evidence this had been considered as the least restrictive option. One person and a relative told us they felt more could be done assess risks associated with accessing the community, to give people greater opportunity to do so. Other relatives told us they felt risks were managed well and felt their loved ones were safe from harm. Relatives told us they were not always involved in reviews of their loved ones’ needs. The registered manager told us face to face meetings had been arranged to involve people and their relatives, but these were poorly attended by relatives.

Staff we spoke with were aware of most risks to people and their role in monitoring and managing these. However, some staff we spoke with could not demonstrate their learning from training, such as safeguarding adults, and how this should be applied to keep people safe. There was more work required on the effectiveness of staff training, to ensure staff had the knowledge and skills to work safely and knew how to apply these in their day-to-day work. We saw there were some gaps in staff training, which the registered manager had not identified. The registered manager told us they had escalated concerns in relation to risk management within the service to the provider, but we found many of these known risks had not been actioned by the provider. The registered manager and clinical lead were both receptive to feedback from us in relation to concerns we shared with them on the management of risks and involving people in this process. Staff told us how they supported people in a way to encourage independence whilst monitoring the associated risks but felt more could be done to support people to have access to the community.

We observed hazards relating to the care environment and care equipment in use, which posed significant risks to people using the service and had not been addressed by the provider. This included trip hazards, unrestricted access to high-risk areas and the poor standard of overall maintenance of the premises. Staff were observed to be responsive to people’s changing needs. For example, for 1 person who became very unsettled during lunchtime, staff recognised how the busy environment impacted on the person, and they were supported to leave the dining room. This was to reduce the risks to the person and others in this area. We observed areas leading to the main exit of the service were only accessible via key codes or fobs; this was due to people who were at high risk of leaving the service unaccompanied and lacked capacity to do so. We observed 1 person who had been supported to obtain an electric wheelchair. The person’s safety and competency to safely manage this in the community was assessed. This enabled them to access the community independently.

Risks to people had not always been assessed with them or clear plans developed, with accompanying guidance for staff, for managing these. Some people's support plans lacked clear guidance for staff about their role in monitoring risks and adopting a consistent approach to managing these. The system for involving people and relatives when assessing, managing and updating risks was not fully inclusive. Although risk assessments had been produced in relation to most people’s known risks, there were some clear omissions, such as the failure to fully assess risks associated with people’s seizures, stoma care and complex mental health support needs. We saw support plans indicating people were receptive to physical touch/interactions from staff needed to be more detailed with clear boundaries for staff to follow. This may prevent any misinterpretation of what is acceptable and professional and reduce risks associated with such interactions, particularly for younger adults who are supported at the service. Improvement was needed in the updating of support plans and risk assessments following the implementation of a new electronic care planning system. Decision-specific mental capacity assessments or best interest meetings related to identified risks had not always taken place when required, such as prior to the implementation of restrictions upon people who smoked. A matrix to monitor applications for DoLS authorisations and the outcomes of these was in place. We saw 1 person had conditions applied to their DoLS authorisation and there was evidence to demonstrate this condition was being met by the staff. Reviews of risk assessments were not always robust and did not identify the conflicting information or lack of robust information which we found and discussed with the registered manager and clinical lead. The registered manager had a record in place to monitor when risk assessments were due to be reviewed.

Some relatives told us they did not feel the care environment was well maintained. A relative told us, “The bathroom lino is damaged; it’s been like this for months.” Another relative told us, “I feel [name] is safe because the people that work there are wonderful. They will do anything for you, but the [person’s] bedroom it’s terrible and tatty. The whole home is very bad, the room is very dim, the home needs decorating, the window sashes don’t work very well, and it could be cleaner. I have to clean down the table when I visit.”

The registered manager and clinical lead demonstrated they wanted to ensure people were safe by the actions they had taken to monitor and reduce identified risks in the service. However, risks associated with the premises and equipment which they had escalated had not always been actioned in a timely way by the provider. Staff were able to tell us what actions they would take if they found faulty or damaged equipment. However, our findings demonstrated the processes for rectifying these issues were not robust. The on-site maintenance officer took timely action when they were made aware of issues. They told us where they were unable to resolve these, they reported the issues to the registered manager to escalate to the provider.

We observed multiple significant unaddressed risks within the care environmental such as ineffective control of hot water distribution temperatures placing people at risk from scalding; unrestricted access to hazardous items and areas due to unsecured doors on which keypads were absent or deactivated; and risk of surface burns from broken or missing radiator covers in both private rooms and communal areas. There were no risk assessments in place regarding mitigation of these risks. The provider’s audits on the care environment and equipment were not robust and impacted on the safety of people and timeliness of repairs being carried out. We saw fire safety deficiencies identified from a fire risk assessment in December 2023 had not been fully actioned. Recommended actions to be completed within 12 weeks were still outstanding. This placed people at increased risk from potential arson due to the proximity of the bins to the main road.

Processes for monitoring and ensuring the safety and upkeep of the premises were not effective. Potential risks within the care environment, including the condition and cleanliness of the care equipment in use, were 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 many of the issues we found during our assessment. There was a system in place for staff to record and report areas requiring maintenance or equipment requiring repair. However, where maintenance issues, included those identified from audits and checks on the premises and equipment, had been escalated to the provider, they had not always taken prompt action to keep people, staff and visitors safe. We observed staff bags, coats and personal food items were left in areas which could be accessed by people living at the service, placing them at increased risk of harm. Storerooms were not always locked to ensure people could not access items such as flammable creams and sharp items. The staff call system was not audible in all required areas of the service, and not compatible with other equipment such as pressure alarms and person-specific adaptive equipment to enable people to remain independent. For example, 1 person needed to be supervised when smoking as the current system did not enable adaptations to allow them to be able to raise the alarm from outside. This was a source of frustration for that person as it impacted upon their independence and well-being. Cleaning trollies containing potentially harmful substances were within sight of the housekeeping staff when cleaning rooms. Some functioning keypads were used to restrict access to high-risk areas of the service. Data sheets to guide staff on actions to take should cleaning products or chemicals be swallowed or come into contact with people’s eyes or skin were accessible to staff.

Most people and relatives told us they or their loved ones were normally supported by staff who knew them well and recognised risks. However, 1 relative told us, “They [staff] don’t always seem to know about his condition when I ask.” Most people and their relatives were satisfied with staffing arrangements at the service. One relative told us, “There appears to be adequate staff, [person] is quite happy with them. They [staff] pop in when I’m there. It’s normally regular staff when I go at weekends.” One person told us, “There’s always staff around, giving us tea and things.” However, 1 relative told us they felt more staff would improve the support their loved one received. They said, “Staff are usually around. They do what they need to do. It’s mainly functional there’s no stimulation”. Another relative said, “They [staff] do seem slow in doing things like not changing [name’s] pads quickly enough and [name] is frequently not wearing their glasses.” Most people told us they felt the staff were knowledgeable and they felt safe.

Most staff felt they had enough training, information, and support to support people safely. However, we found staff’s responses to us did not always demonstrate the effectiveness of their training. For example. although staff told us they had received fire training, their knowledge of the service’s fire safety procedures was poor. In addition, we found staff lacked awareness of what safeguarding people meant, and the action to take in the event they had abuse concerns, aside from speaking with the registered manager. We fed this back to the registered manager. The registered manager told us staffing levels were adjusted according to people's needs. Most staff told us they felt the staffing levels were adequate, but some felt they wanted to be able to spend more meaningful time with people. Staff told us they received an induction and had opportunities to shadow experienced staff to ensure they knew how the service worked and understand people's needs.

We observed that staffing ratios were adequate to meet people’s assessed needs during our time at Hafod Nursing Home. Staff were available to support people when they needed support or guidance. Most staff knew people well. This was demonstrated by the positive interactions between people and staff and staff responsiveness to their requests. We observed appropriate staffing levels being maintained during the days we visited the service including for those who required 1 to 1 staffing. Some people were unable to leave their room or chose to stay in their rooms and did not have call bells. In these instances, enhanced observations had been implemented and additional pressure alarms installed to alert staff should someone stand or fall from bed. The registered manager and clinical lead told us they had worked hard to recruit permanent staff to provide stability and continuity of care for people using the service.

The provider had not always ensured staff had completed all the training they needed. The provider’s staff training records indicated staff received regular training in many areas, but there were gaps which needed to be addressed. This included training specifically to support people with learning disabilities as per their legal requirement, training in people’s mental health needs and training in the care of stoma sites. Nurse competency assessments were completed to ensure nursing staff had the skills and knowledge to carry out their roles safely and effectively. However, these had not been reviewed since their implementation and completion. The registered manager told us these should be reviewed annually and would address this, and the other training shortfalls shared with them. In addition, staff had not consistently participated in fire drills, in line with the provider’s policy. The registered manager’s fire audits had identified this shortfall, but they and the provider had failed to ensure this practice was completed in a timely way. This placed people and staff at increased risk of harm in the event of a fire. Once online learning was completed there were no checks or discussions completed, or observations recorded to evidence staff learning and implementation of their learning, with the exception of medicines and moving and handling. The registered manager used a dependency tool to ensure staffing levels were safe and a rota system was in place. Although there were gaps in the rota at times, the registered manager assured us the staff numbers were in line with the dependency tool and numbers of people living at the service, at that time. The registered manager followed safe recruitment practices ensuring new staff had the relevant checks carried out prior to commencing work and there was an induction process in place.

Some people and relatives told us they felt the service was clean and tidy and they were happy with the standard of hygiene. However, others told us they felt it was very tired and shabby, and rooms were not always clean. One relative told us, “Sometimes the [person’s] room is not very clean.” Another relative told us they had to clean the table in their loved one’s room each time they visited, and another spoke about how the bed clothes in their loved one’s room were ‘filthy’ on 1 occasion when they visited.

There was a team of housekeepers who were overseen by the infection prevention and control (IPC) lead for the service. The IPC lead told us they understood their role and had received additional training to understand what they needed to look for when completing audits, and the actions to take in the event of infectious outbreaks. The standards of hygiene we observed did not demonstrate the IPC audits were effective. Most staff had received IPC training.

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 also found some pressure cushions were dirty and some armchairs had stained seats. Protective coverings to armchairs, dining chairs and a foot stool were observed to be very worn exposing the porous under-fabric. Some equipment to support people when bathing or using toilet facilities were dirty and rusty. This was not conducive to good IPC practices. We also saw that continence aids had been removed from protective wrappers and in 1 case these were stored next to a dirty linen trolley in a bathroom with a toilet which could spray contaminated water onto them. Prescribed creams and toiletries for people were all stored together and were not consistently labelled. This meant these could be used for the incorrect person exposing them to risk of cross infection. We also observed cupboards and shelving where the wood had become exposed meaning it could harbour germs and not be effectively cleaned. This has not been identified on the recent environment audit for repair or replacement. We observed no concerns with the hygiene standards in the laundry or kitchen. Both areas were clean and organised. However, the keypad code number to gain access to the laundry had the entry code recorded underneath it, which was not safe practice. Overall, we observed staff following good IPC practices with the correct and safe use of personal protective equipment (PPE). PPE stations were suitably stocked with appropriate equipment including gloves, aprons, and hand gel. We observed staff following good practice in the correct use and disposal of PPE.

Processes to assess and manage the risk of infection on the premises were ineffective. We identified multiple significant concerns regarding the cleanliness and hygiene of the care environment and care equipment in use, which increased the risk of infection to people, staff and visitors. These included damage to walls, flooring and furniture which hindered effective cleaning, and visibly-dirty toilet seats and shower chairs. Although the provider had an IPC policy and procedure, which stated that damaged furnishing and equipment would be replaced, this was not being followed. The IPC lead carried out weekly IPC checks, which had identified some of the IPC concerns we found, and the registered manager did regular ‘walkabouts’ to observe the care and the care environment. However, these had not enabled the provider to ensure appropriate IPC standards were maintained. Once we brought our concerns around standards of IPC to the registered manager’s attention, they took some actions designed to address these.

People and relatives told us they did not have any concerns in relation to the handling and administration of their medicines. However, we identified some areas of concern in relation to the safe storage and recording of medicines which had the potential to cause harm to people, including from cross contamination. We observed staff gain consent prior to administering medicines and talking to people whilst helping them take their medicines to offer reassurance.

Staff told us they had received training and competency assessments and felt confident in the administration of medicine. We saw evidence of such assessments taking place. However, the practices we observed relating to the storage and use of topical medicines indicated staff may lack understanding of associated risks, including the risk of cross infection. The registered manager told us that the new pharmacist used by the service had been really good and had worked with them to improve medicines processes. This included tracking the use of ‘as required’ pain relief and then increasing the strength of people’s pain-relieving patches to ensure they remained free from pain.

The provider had policies and procedures designed to ensure people’s medicines were safely managed. However, we found concerns relating to the handling and administration of medicines. People’s topical medicines were not always stored securely or clearly labelled, increasing the risk of ingestion, misuse and cross infection. Prescribed and non-prescribed skin creams were stored in boxes in an unlocked cupboard on the ground floor. Multiple open containers of the same cream for different people in the same box. Most of these creams did not include details of people’s names or dates of opening. One person was prescribed blood thinning medication and was high risk from falls. There was not a robust support plan or risk assessment to guide staff on the risks associated with taking this medicine and implications for the person’s care, including the actions they should take in the event of a fall. Guidance for ‘as required’ (PRN) medicines was not always detailed enough. This was in relation to the application of topical medicines and lack of guidance for staff to follow on where these should be applied or how often. One person was prescribed medication as part of their ‘recovery’ plan in relation to their diabetes. There was no protocol in place to guide staff on when to use this medicine or how long to wait before seeking medical attention. This meant we could not be assured such medicines were always used appropriately and as prescribed. Clinical rooms were locked and clean and temperatures including the fridges were checked and recorded. The recorded and actual balances of the medicines were correct. We saw where a medication error had been identified swift action had been taken to seek advice. Most care plans contained information about how people wanted to be supported to take their medicines. Medication audits took place which identified actions which were addressed by the clinical lead in a timely way but had failed to identify the concerns we found.