Hatfield Manor

This responsive assessment was carried out as we had received concerns about safety at the service including staffing levels, medicines administration and the management of the service. We looked at all of the quality statements, under all 5 key questions.

This was the first assessment carried out at the service. We found the provider was in breach of the legal regulation relating to safe management of medicines, staffing and governance.

The service did not have a registered manager. At the time of this assessment, the deputy manager was managing the service on a day-to-day basis with support from 2 senior managers from the provider organisation.

Quality assurance systems and processes were in place but had not been robustly implemented to ensure safety and quality improvement. Management changes had led to an inconsistency in leadership, impacted upon the culture and affected oversight of the service. A service improvement plan had been put into place by the provider at the time of our assessment however, some issues we found had not been identified and some improvements had not been made promptly.

The provider had not ensured sufficient staff were deployed. Staffing levels received mixed reviews from relatives and staff. We found that staffing levels had fallen below the level determined as needed by the provider on a number of occasions. We found gaps in induction records.

Staff support processes were not consistently being provided. Staff were not being supported via team meetings or supervision. In addition, some staff had not completed training relevant to the needs of people they were assigned to provide care to.

People’s medicines were not always managed safely. Medicines were not being administered in a timely manner, and we found concerns in relation to the storage of medicines.

We observed a contrast in people’s experiences of living at the service with access to facilities, activities and engagement opportunities varying between floors of the service. The management team responded positively to our feedback regarding the disparity in opportunities for people. They were responsive to the assessment process and were committed to developing the service to ensure safe care at Hatfield Manor. They took immediate action to improve access for people and confirmed they would explore further opportunities for activities for all people. This included the provision of resources and training for staff.

People’s needs were assessed before moving into the service. Staff and external teams worked well together. People had access to a range of health services. Care plans we reviewed were evidence-based and contained sufficient information for staff to support people’s needs.

People were treated as individuals, and we saw staff treating people with kindness, dignity and respect. There were plans in place to support people’s future care wishes, however planned outcomes for people would benefit from further detail.

Following the assessment, the management team told us how they were addressing some of the issues raised during the assessment and were taking action to make the necessary improvements.

We have asked the provider for an action plan in response to the concerns found at this assessment.