Bradbury House

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good.

This meant people were safe and protected from avoidable harm.
 

This service scored 66 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There was an active culture of learning and improvement at the service. Lessons learnt were shared with staff during handovers, staff meetings, unit meetings and in one-to-one meetings with staff. Accident and incident forms reviewed confirmed the service had systems in place to monitor action taken to prevent reoccurrence.

People told us that they felt safe at the service. A person told us “I have lived here for several years, and I have never doubted that I am safe”
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. The provider made sure there was continuity of care, including when people moved between different services.

The provider and staff worked well with professionals which promoted safe care. They employed the use of an external physiotherapist to support people in maintaining independence and provided plans for staff to follow when changes in people’s need were identified. People had access to weekly GP reviews. The GP advised us staff were very proactive in raising any concerns which needed medical attention. They told us “Staff know when hospital treatment is necessary and when it’s not. Lots of chronic health issues can be addressed [by the service/staff] and we work on a management plan to support people”.

The provider had a system in place to promote safe transition to hospital.
They generated a “Hospital Pack” from the electronic care plan system which outlined people’s care needs, medical conditions, any allergies and provided them with a copy of their medicine administration record. Personal belongings and items of clothing were sent in a red bag to ensure the person had access to items they may need. This reduced the risk of items going missing and ensured that relevant health information was shared with professionals.
 

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

There were clear systems in place for safeguarding people. When a concern was identified, the provider communicated with the local authority to ensure the concern was investigated, and appropriate action taken.

Staff were trained in safeguarding. Staff we spoke with demonstrated a good understanding of safeguarding processes and whistleblowing. They explained what concerns they would raise and who they would report them to.

People told us they felt safe living at the service and when they received care. Their comments included, “Yes, I feel safe. I can leave my door open at night,” and “I have lived here for several years, and I have never doubted that I am safe.”
 

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People had access to call bells in their bedrooms, and the service had clear processes in place to monitor wait times as well as the use of these. This ensured any changes in need were identified from this monitoring

Each person had a personal emergency evacuation plan (PEEP) which provided guidance on the support they needed if they had to be evacuated from the service. However, there were some inconsistencies noted around where people were located in the building or reference if they required the assistance of mobility aids to be safely evacuated. This meant emergency professionals may not have enough information to assist people to leave the building safely. This was discussed with the manager during feedback and they will review these.

Risks to people associated with their nutritional needs were not always identified. We looked at a person’s care plan which identified they required softer foods via the International Dysphagia Diet Standardisation Initiative (IDDSI) framework to manage risks associated with dysphagia (swallowing difficulties). However, the person chose not to follow all the advice from their Speech and Language Therapist (SALT) Assessment and preferred to eat foods which may pose a risk of choking. In response to our feedback, the service reviewed this with the person and updated their care plan and risk assessments to reflect their preferences and wishes. This ensured risks were mitigated and managed appropriately. The service provided us with further assurances they will review and amend their processes around support for people with IDDSI diets.

We reviewed a care plan for a person who had recently moved to the service and identified inconsistencies. For example, an eating and drinking checklist had been filled upon admission without a mealtime observation being completed. Continence assessments were also contradictory. This meant the information was not factual and would not have fully identified support needs or risks. The provider set out it was reviewing care plans on a regular basis and in response to feedback from the visit, were implementing further improvements to their systems and processes for care plans.
 

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service was well maintained and had been refurbished to a high standard. The environment was welcoming, homely and accessible to meet people's needs. Further improvements were planned, including refurbishment of bathroom facilities.

Adequate storage arrangements ensured corridors and communal areas were kept clear and free from obstruction, reducing environmental risks. Storage areas were well maintained, organised, secure and effectively managed.

Environmental risk assessments were in place, regularly reviewed and updated, providing assurance the environment was safely managed. Risk assessments were completed for maintenance works taking place at the time, helping to ensure these activities were carried out safely and minimising potential risks.

The provider had effective systems in place to ensure good oversight of the servicing and maintenance of equipment and had up to date certificates for key safety systems, including gas safety, fixed electrical wiring, fire safety systems such as emergency lighting, alarms and extinguisher servicing, portable appliance testing (PAT), legionella testing and Lifting Operations and Lifting Equipment Regulations (LOLER) inspections for hoists and beds.

Regular fire checks were carried out, including checks of emergency lighting, fire doors and fire detection systems. An up-to-date fire risk assessment was also in place.

In addition, water temperature monitoring was undertaken, and first aid provision was in place, including first aid boxes and access to a defibrillator.

Regular house health and safety checks were undertaken, alongside health and safety meetings, which provided effective oversight of health and safety. A QR code -based maintenance system was in use, enabling staff to report and track maintenance issues in real time, supporting timely follow up and good oversight of maintenance to promote a safe environment.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were always enough staff to provide support for people. Rotas showed staffing levels were planned in line with the needs of the service with sufficient flexibility to respond to short notice sickness and training needs. The service had appropriate management oversight and was supported by additional staff roles including administrative, housekeeping, catering and maintenance staff, as well as medication technicians whose responsibility it was to administer medicines. This ensured there were sufficient roles in place to meet the operational needs of the service.

The providers recruitment policy was reviewed and up to date. However, in 2 of the recruitment files reviewed, Disclosure and Barring Service (DBS) checks had been received after the staff members had started their employment. There was no formal risk assessment in place at the time to mitigate any potential risk arising from this. The registered manager advised us the staff members had worked in a supervised capacity whilst waiting clearance, and rotas and supporting emails were provided to demonstrate this. In response to our feedback, the provider introduced a formal risk assessment process to ensure risks associated with delayed DBS clearance are assessed and recorded.

In other staff files viewed, gaps in employment had not been clearly explored or recorded, and in 1 staff file a reference had not been obtained from the most recent employer. Following feedback, the registered manager took action to strengthen their recruitment process by adding prompts to their application forms and interview template record to ensure these checks are completed and documented consistently.

Information relating to staff health was not always used to assess fitness for the role. Staff completed a health questionnaire, but where relevant medical conditions were disclosed, there was no evidence these had been considered in relation to their capability to carry out their duties or whether any reasonable adjustments were required. In response to our feedback, the provider implemented a process to ensure information obtained through medical questionnaires is reviewed, assessed and recorded to demonstrate staff fitness for their roles and any required reasonable adjustments.

Systems were in place to ensure staff were suitably trained and skilled for roles, with staff supported to take on additional training to gain a qualification in care or management. Staff had access to a range of face-to-face training facilitated by external trainers and considered mandatory by the provider, with refresher training scheduled to ensure staff remained suitably skilled. New staff were inducted and all new staff had an induction booklet to work through to support a consistent approach to inductions. Staff were provided with regular supervision and annual appraisals to support staff performance and professional development. The provider facilitated a leadership development day inspired by their values which promoted teamwork, communication, learning and new ideas. The provider had effective systems in place to monitor and have oversight of training to ensure that staff remained suitably skilled and trained for their roles.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean, hygienic with systems in place to maintain a high standard of cleaning, including cleaning of equipment such as wheelchairs and hoists. Cleaning schedules were in place which were signed off when completed. The cleaning schedules for the kitchen showed gaps in completion. This was fed back to the registered manager and addressed with the external catering service.

Staff were trained in infection control, and policies were in place to guide their practice. Infection control procedures were regularly audited to ensure compliance. The service had a named staff member as an infection control ambassador who had responsibility for the oversight of infection control. Personal protective equipment (PPE) stations were located throughout the service, which were fully stocked, checked and accessible to staff.
 

The provider did not make sure that medicines and treatments were safe and met people’s needs. Care plans were not always up to date and did not always contain sufficient information about medicines risks and side effects.

Medicines, including medicines which require additional storage due to potential of abuse, were stored securely and keys to the medicines room were restricted to authorised staff only. Staff carried out regular medication checks, and no discrepancies were found. Room and fridge temperature monitoring was taking place daily in the medicines room, but not in residents’ rooms which is where individual medicines were stored. There was no risk assessment in place to determine whether residents' rooms needed temperature monitoring. This meant the provider could not be assured medicines were stored within safe temperature ranges, posing a risk to their effectiveness and safety. Since our inspection took place, the provider is now reviewing their policies to ensure medicines are stored appropriately.

People received medicines safely and as intended by the prescriber. Electronic Medicines Administration Records (eMARs) were in place, which provided staff with accurate information about the medicines.

Care plans we reviewed did not always have the necessary information to support people with their health needs and prescribed medicines. For example, a person who was prescribed a blood thinner did not have the risks of bruising and bleeding appropriately highlighted in their care plan. Another person who was prescribed medicines for Parkinson’s disease, which are time critical medicines, did not have the importance of timely administration highlighted in their care plan. One person’s care plan incorrectly stated they were taking a blood thinner, but this was stopped a year prior to the inspection. However, this was a recording issue for the provider to address, and we found that there had been no impact on people.

When required (PRN) protocols were present, however, for a variable-dose PRN medicine (e.g., take 10–15ml), there was no written guidance in protocols to help staff decide what dose to give. This meant staff did not always have clear instructions on how and when to use PRN medicine. The provider updated these during our inspection to ensure correct guidance was in place for staff.

The provider regularly communicated with the doctor’s surgery and flagged necessary people for medication reviews. The provider regularly accessed the doctor's records to reconcile new cycles of medicines against current prescriptions.

There was an auditing and stock management system which provided assurances medicines were being given safely and as prescribed. Where errors were identified, learning and improvement from these were implemented and embedded into practice by the service.

Staff received training in medicines management annually which included competency assessments.