Bricklehampton Hall

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 inadequate. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At our last visit the provider did not have a proactive and positive culture of safety based on openness and honesty. Staff did not listen to concerns about safety and did not investigate and report safety events. Lessons were not learnt to continually identify and embed good practice. At this visit, some improvements had been made. The provider had updated and revisited their schedule of works to ensure where improvements were needed, these were monitored, and each action had set time scales for completion. However, we queried some of the value of the actions and their ongoing monitoring. For example, during the last inspection it had been identified daily walkarounds were not being completed regularly. At this inspection, daily walkaround documents had been reviewed and updated to include additional information about sensor mats and wounds, but they had still not been completed consistently. This meant there may have been missed opportunities to identify any concerns and share information about people. During June 2025 only 11 days had been completed. We shared this with the area manager who told us they would monitor this going forward. Additionally, staff had undertaken both online and face to face training in dignity and respect, manual handling, falls prevention and wound care. Nursing staff were receiving 1-1 support from the area manager on reporting and documenting incidents. Two staff had completed advanced skin care training, and some staff had been allocated as dignity champions. Further training was also booked for pressure ulcer awareness. When reviewing some of the wound care questionnaires following the training, we identified out of 27 staff, 15 either had identical or similar answers which showed staff had not always individually considered their answers and responses. We shared this with the area manager and consultancy team who told us they would revisit the questionnaires with the relevant staff team members.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider had revisited their safeguarding processes since our last inspection and some improvements had been made. Where a person had raised concerns about potential abuse, appropriate actions had been taken to ensure they had been listened to and safeguarded. A new safeguarding tracker had been implemented which had detailed sections to enable the provider to have better oversight of any safeguarding referrals and what actions had been taken. The area manager had completed a piece of work for June 2025 called an accident and incident review, this was to collate information regarding any accidents or incidents which occurred. It identified what actions had or hadn’t been taken, whether it required a safeguarding alert, if the persons next of kin had been informed and what lessons had been learnt. This had highlighted a number of previous missed processes which the provider had already started to take action on. The area manager told us they would be contacting the local authority, safeguarding team and the Care Quality Commission to discuss how these should be reported due to the high number incidents. They told us this piece of work will continue as the provider starts looking at previous months. Although we acknowledge improvements had been made, more time was needed to ensure these were embedded into the service.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We saw some improvements had been made to the environment since we last visited the service. The provider had repaired and levelled some of the communal flooring areas to create a smoother, more even surface for improved safety and accessibility. Further areas which posed a lower risk to people were also due to be completed over the coming months. There was signage throughout the home where some floors were uneven and posed a risk to people. Areas of the service where there had been black mould had been treated, some areas had been repaired and painted, whilst others were on the providers schedule list to be completed by the end of September 2025. Although we acknowledge improvements had been started, more time was needed to ensure all of required works had been completed.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

During our previous visit we had identified some manual handling equipment was not stored appropriately and posed a risk with infection control measures. The provider had designated an unused bedroom which was now being used as storeroom to effectively store equipment which had appropriate signage.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.