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Bradbury House Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 9 August 2019

About the service

Bradbury House provides planned and emergency short term respite care for up to ten people with a learning disability, some of whom may have additional physical care needs. All accommodation is on the ground floor and in single rooms. There are shared recreational rooms and accessible gardens.

The service did not always consistently apply the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence

The service was bigger than most domestic style properties. It was registered for the support of up to 10 people. The size of the service having a negative impact on people was mitigated by the building design which included wide corridors and level access for people with mobility needs.

People’s experience of using this service and what we found

Risks were not well managed and placed people at potential harm. Risks were not consistently assessed and action plans developed on minimising the identified risk. Where people sustained injuries there were not investigated. This meant staff were not given clear guidance on the measures to reduce the risk.

People were placed at potential risk of harm.

Safeguarding procedures were not followed. This was despite the staff having a good understanding of safeguarding people from abuse and having these procedures on display for reference. Some safeguarding referrals had been made in response to relative’s concerns, but safeguarding referrals were not made for all abuse allegations.

Accidents and incidents were not well managed. This meant trends were not identified and there was little evidence of learning from these events. Organisational policies and procedures such as risk assessments were not always followed. CQC was not notified of all reportable events.

The staff told they “now” felt confident to report poor practice and that their concerns would be taken seriously.

National recognised induction programme was not followed for new staff. . For some staff the induction covered reading care plans and touring the property. The manager has taken steps to ensure the most recently employed staff complete inductions that meet Skills for Care standards. Some staff were assisting with behaviours deemed to be challenging when they had not attended the appropriate training.

The training matrix was not accurate and up to date. The names of staff on the training matrix did not correspond with the names on the staff rota. This meant there was a lack of monitoring on the training staff had attended.

One to one staff supervision meetings with their line manager were not regular although action was taken to address this.

People were not fully supported to have maximum choice and control of their lives. Staff did not support people in the least restrictive way possible and in their best interests.

Mental capacity assessments were in place for some decisions. Where people lacked capacity there were some best interest decisions to impose restrictions through the deprivation of liberty safeguards (DoLS) process. Applications for DoLS were in place for some people that had one to one or two to one support. However, capacity assessments were not in place for all the people that were having this support. This meant steps were not taken to ensure this was the least restrictive action.

People were not able to leave the home independently as there were entry door systems in operation. The staff told us the people using respite care were always accompanied in the community. DoLS were not in place for all the people that had their liberty restricted. Where DoLS applications were in progress they were not reviewed to ensure the restrictions were appropriate.

While staff said the team was "fractured", they said the leadership had improved. The culture and practice was not always

Inspection areas


Requires improvement

Updated 9 August 2019

The service was not always safe.

Details are in our safe findings below


Requires improvement

Updated 9 August 2019

The service was not always effective.

Details are in our effective findings below.



Updated 22 May 2019

The service was caring

Details are in our Caring findings below.



Updated 22 May 2019

The service was responsive.

Details are in our Responsive findings below.


Requires improvement

Updated 9 August 2019

The service was not always well-led.

Details are in our well-Led findings below