CQC report explained · a nursing home
What the CQC found at Hafod Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, November 2021
Rated Requires Improvement, with an Inadequate well-led rating; inspectors found serious safety and maintenance problems despite kind care and some improvements.
This was an unannounced focused inspection on 14 July 2021. Inspectors spoke with people, relatives and staff, and reviewed care, medicine, recruitment and management records. They checked Safe, Effective and Well-led. Caring and Responsive were not inspected at this visit.
The home was clean and people generally said they felt safe. Staff were described as kind and knew people's needs. Medicines, care plans, safeguarding referrals and staffing were mostly managed appropriately.
However, inspectors found serious problems with fire doors, fire exits, windows, repairs and the general condition of the building. The environment was not suitable for people living with dementia and wheelchair users had limited independent access to the garden.
The provider's checks had not led to repairs being completed. The overall rating stayed Requires Improvement, and Well-led fell to Inadequate. The provider had started repairs and introduced some extra checks after the inspection, but the home remained in breach of regulations.
Kind and knowledgeable staff
People and relatives spoke positively about staff. Inspectors saw kind interactions and found that staff understood people's needs and how to support them when they became upset.
“We saw kind interactions with people.” from the report
Medicines managed safely
The medicine records checked showed that people received their medicines as needed. Guidance was available for medicines given only when required.
“Medicines were managed safely. Records indicated people had received their medicine as required.” from the report
Consent processes improved
The provider had improved mental capacity assessments and best-interest decisions. Appropriate applications had been made where people were being deprived of their liberty.
“At this inspection enough improvement had been made and the provider was no longer in breach of regulation.” from the report
Care records and referrals
The care plans inspected were described as clear and person-specific. They showed regular reviews and appropriate referrals to healthcare professionals.
“The care plans we looked at had been rewritten within the last six to 12 months and were comprehensive, clear and concise.” from the report
Fire and window safety
seriousSeveral fire doors and seals were damaged, one fire exit was blocked and some windows had unsafe or missing restrictors. Inspectors said this placed people at risk of avoidable harm.
“We found three fire doors had combustible material (wooden blocks) affixed to them” from the report
Poor building condition
seriousThe home had damaged ceilings, walls, flooring and paintwork. Some repairs had been known about for a long time but had not been completed promptly.
“The provider had failed to ensure the building was a safely maintained and pleasant home environment for people to live in.” from the report
Not dementia-friendly
needs fixingBedroom doors looked the same, signs were inconsistent and the flooring could cause confusion. The environment did not support people living with dementia to move around independently.
“The home environment requires improvement and is not dementia friendly and did not follow current national guidance for dementia friendly environments.” from the report
Limited wheelchair access
needs fixingThere were no ramps from the lounges to the garden, limiting independent access for wheelchair users.
“Independent wheelchair access to the garden area from the lounges was limited due to no ramps being in place.” from the report
Weak management oversight
seriousAudits and spot checks had not driven timely improvement. They had failed to identify or resolve important safety, maintenance and mask-wearing problems.
“The provider lacked oversight to make sure governance processes that had identified repairs, were completed in a timely manner.” from the report
- 01Which fire doors, seals, windows and fire exits identified in the report have now been repaired or made safe, and when were they checked?
- 02What repairs to the leaking roof, downstairs bathroom, carpets, paintwork and garden have been completed?
- 03What changes have been made to help people living with dementia find their bedrooms and move around independently?
- 04How can wheelchair users now reach and use the garden independently?
- 05Can you show us the latest monthly audit reports and explain how outstanding repairs are tracked to completion?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 6 November 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2020
Rated Requires Improvement; inspectors found kind staff and safe medicines, but legal consent, care records and management systems were not reliable enough.
This was an unannounced planned inspection on 9 and 10 July 2019. Inspectors spoke with seven people, six relatives, ten staff and two visiting professionals. They observed care and checked care, medicine, staffing and management records.
The home cared for 22 people aged 65 and over, although it could support up to 29. People generally said they felt safe, staff were kind, the home was clean and medicines were given as prescribed. However, inspectors found mixed views about staffing, gaps in risk records, inconsistent activities and some staff training that was not effective.
The home was still rated Requires Improvement in all five areas: Safe, Effective, Caring, Responsive and Well-led. This means some care was good, but important parts of the service were inconsistent and there was an increased risk that people could be harmed.
The previous inspection also rated the home Requires Improvement. The report says enough improvement had not been made and the home was still breaching regulations. Warning notices were issued about consent and governance.
People felt safe
People told inspectors they felt safe. Staff knew how to recognise and report abuse, and the provider took appropriate action when concerns were identified.
“People told us they felt safe and staff knew how to recognise signs of abuse and how to report them.” from the report
Medicines
People said they received medicines as prescribed. Inspectors found improvements in records for transdermal patches and guidance was available for medicines given when needed.
“People told us they received their medicines as prescribed.” from the report
Kind and respectful care
People and relatives spoke positively about staff. Inspectors observed kind interactions, and staff supported people's privacy, dignity, independence and religious needs in most situations.
“We observed kind and caring interactions.” from the report
Clean environment
The home had a cleaning schedule and staff used protective equipment when needed. People and relatives described the home as clean.
“Domestic staff were in place and a cleaning schedule was followed to ensure the home was clean and free from infection.” from the report
Prompt complaints handling
The provider had a complaints process and complaints were answered in a timely way. People knew how to complain.
“The provider had a complaints process in place and complaints had been responded to in a timely manner.” from the report
Consent and restrictions
seriousMental capacity assessments did not cover each decision properly. Inspectors found a risk that people could have their liberty restricted without the required legal safeguards and issued a warning notice.
“We found the principles of the MCA were not being followed and people were at risk of having their liberty restricted.” from the report
Weak management checks
seriousAudits did not identify problems with care plans, consent assessments, training, infection control and fire exit access. The provider remained in breach of governance requirements and received a warning notice.
“There were insufficient systems in place to monitor and improve the quality of the service.” from the report
Care records and dietary safety
seriousOne person's care plan did not match their nutritional needs. They were served food that should have been avoided, and the staff member supporting them was unclear about the correct diet.
“This placed the person at increased risk of unsafe care and demonstrated the kitchen's staff knowledge required improvement.” from the report
Limited activities
needs fixingActivities were not consistent and inspectors saw people without stimulation for periods of the day. There was no evidence of how people cared for in their bedrooms were included.
“During the inspection we observed people sitting and looking around with no stimulation for periods of the day.” from the report
No registered manager
needs fixingThere had been no registered manager for over a year. People were unclear who was in charge, and the proposed registration application had not started at the time of inspection.
“At the time of the inspection there had been no registered manager in post for over a year.” from the report
- 01How do you now make sure each person's mental capacity assessment covers the specific decision being made?
- 02How do you make sure staff understand DoLS, consent and least restrictive care?
- 03Who is currently responsible for managing the home, and has the registered manager application been completed?
- 04How do you check that care plans reflect dietary needs and other risks before staff provide care?
- 05What activities are now available, including for people who spend time in their bedrooms?
This was an unannounced planned inspection covering all five CQC questions, with the previous Requires Improvement ratings reassessed. This explanation was written from the published report of 5 February 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Hafod Nursing Home
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- November 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- February 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- July 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 10 March 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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