Hadfield House

At this inspection, we found the provider was in breach of 2 legal regulations in relation to good governance and staffing.

People were not always protected from avoidable risks. Incidents were not consistently reviewed by management and learning from safety concerns was not always shared with staff. Safeguarding concerns were not always reported appropriately to CQC, safeguarding training completion rates were low and effective oversight of safeguarding concerns was not demonstrated.

People’s key information was not always obtained when they moved into the home and hospital passports were not consistently up to date. Care plans and risk assessments did not always contain clear, accurate and sufficiently detailed information to guide staff safely. Medicines records were not always complete and there was insufficient evidence that staff had received appropriate medicines training and competency checks. Staff did not always receive effective supervision, support and development. However, the environment and equipment were safe, and the home was clean and well maintained.

People did not always have sufficient involvement in their care planning and were not consistently informed about their care plans and risk assessments. Care records did not always provide staff with sufficient information to meet people’s needs effectively. Records relating to nutrition and hydration, observations and mouth care were not consistently completed, and there was limited evidence that people’s goals and aspirations had been considered. Consent documentation was not always in place. Staff worked well with external professionals and people were supported to maintain healthier lives.

Staff treated people, relatives and professionals with care, dignity and respect. People were offered choice and control, and staff responded appropriately to people’s immediate needs and involved external services when required. However, people were not always supported as individuals because care records lacked sufficient detail about their individual needs, preferences and wishes. Some staff also reported that they did not always feel well treated by the provider.

People’s care records were not consistently person centred and did not always provide sufficient information about how their individual needs and preferences should be met. The provider needed to improve how information was provided in accessible formats. End of life care plans did not always contain sufficient detail to guide staff effectively. People and their relatives had opportunities to raise concerns through residents’ and relatives’ meetings. No concerns regarding discrimination were reported.

The service did not have effective governance arrangements in place. Management had not identified or addressed many of the concerns found during the inspection, and systems for monitoring quality, safety and continuous improvement were not sufficiently effective. Staff reported some cultural issues within the service and not all staff felt they were treated well by the provider. However, staff reported that they were treated equally and there were no concerns about discrimination. The provider needed to strengthen its oversight and quality assurance systems to ensure concerns were identified promptly, learning was shared and improvements were sustained.