Bradeney House Nursing & Care Home

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 requires improvement. At this assessment the rating has remained requires improvement.

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.

The service was in breach of legal regulation in relation to regulation 12 peoples safe care and treatment.

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.

The provider did not always have a proactive and positive culture of safety. The provider did not always ensure health and safety concerns were highlighted to mitigate potential harm to people. Lessons were not always learnt to continually identify and embed good practice. Accident and incidents that occurred within the home were investigated and actions were identified. However, actions were not always completed. Staff we spoke with told us they were involved in debriefs after an incident, this included learning for the future. We saw meetings happened every day, these involved all departments of the home and gave the opportunity for staff to share any concerns around people or health and safety within the home. Staff told us they felt confident in speaking up and putting forward ideas for the service to improve. One staff member told us, ‘I understand how to report an accident or incident. Sometimes we have follow up meetings with management’.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care. People who had equipment in place to mitigate pressure areas, such as an air flow mattress, did not have recorded what level the air flow should be set to in their care plan. This is important as the air flow needs to be set according to the person’s weight. We raised this during the inspection. The registered manager confirmed the air flow mattresses in place were automatic and set to people’s weight. Staff we spoke with were not aware on how the air flow mattresses worked. Whilst there was no evidence of impact to people, there was an increased risk of harm to people due to this lack of information. We observed staff did not always respond to call bells in a timely way and at times this impacted on people. People who had specific health conditions had detailed sections in their care plans that advised staff how to care, monitor and maintain their conditions safely. Where a person had a diagnosis of Chronic Obstructive Pulmonary Disease, there was a specific plan in place which provided guidance to staff on how to identify concerns, provide appropriate support within agreed timescales and monitor. The provider had a process for assessing people who expressed a wish to move into the service. This included assessing their personal needs. We saw evidence where people required eating and drinking assessments (SALT), guidance from health professionals had been gained and this had been included in people’s care plans.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. Where people had behavioural needs, these were not always managed in a dignified way. For people who did not want curtains covering their windows and would pull them down, no action had been taken to identify alternative solutions to keep people’s dignity respected. We raised this during the assessment. The registered manager immediately sourced a privacy curtain that could be taken up and down during the day. We found where people were permanently in bed, their bed positioning had not been considered, which left people exposed to the passing public. The registered manager responded positively to our feedback and purchased a privacy curtain for the lower half of the window. There were inconsistencies in where staff recorded people’s behaviours. Behaviour monitoring charts were not used by staff. This meant it was hard to identify concerns, themes or triggers. We raised this to the manager who reviewed records and confirmed staff were not using ABC charts. Some staff were recording incidents in people’s daily notes, but this was not consistent. This meant there was a risk of not monitoring people’s behaviours to ensure they received appropriate care. Staff had completed safeguarding training. 1 staff member told us, ‘I would report anything straight away to the manager or deputy’.

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. Some people had a risk assessment in place to keep them safe whilst independently mobilising around the home, however staff did not follow control measures to keep people safe. We saw safety signs were not always followed. The visitor’s kitchen had a sign to inform visitors and staff to ‘Keep the door closed at all times.’ On numerous occasions we found the door to be open and the room contained a hot water urn. This placed people at an increased risk of harm. We raised this to the registered manager who immediately raised the concern with staff about ensuring the door was checked and locked. We identified some people would enter other people’s bedrooms. We saw bedrooms contained items such as shaving razors, prescribed creams and cleaning liquids which were accessible to people. This placed people at increased risk of consuming hazardous substances or experiencing physical harm. During the inspection, the registered manager provided new locks on personal cabinets in bedrooms to ensure items were safely stored away. We saw care plans had risk assessments present and these identified people’s individual needs.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. We identified safety concerns in the home. There was a communal lounge that had a broken double-glazed window. This had no signage to alert people the window was broken. The glass flexed from the outside, which meant if someone leant against the glass it could have potentially caused the glass to fully smash. This placed people and staff at increased risk of harm. We raised this at the time of the assessment and the provider informed us a new window was on order. We saw some flooring in the home required replacing due to lifting or splitting. The provider assured us there was a plan in place to update and replace areas of the home.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,supervision and development. They did not always work together well to provide safe care that met people’s individual needs. We saw no evidence of a staff dependency tool being used to identify how many staff were required to meet people’s needs throughout the day. We raised this to the registered manager, and they informed us no dependency tool was in place. However, we saw evidence the previous manager had reviewed staffing levels. We observed times when areas of the home did not have enough staff to responsively react to people’s needs. We observed one service user calling out in distress for help, however no staff were around to hear the person calling out. We raised this to the registered manager and were told they would review staffing levels and investigate this concern. The home had activities staff assigned to each area of the home. The staff had enthusiasm and great ideas to get people involved in activities during the day.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. We found areas of the home required additional cleaning and staff did not always ensure the environment was maintained to mitigate the spread of infection. One room had a strong smell of urine and had brown marks on the wall. The window was dirty and had liquid spills down it. The floor had started to lift and there were exposed areas and gaps present. We raised this on the day of assessment to the provider, who took immediate action and had the room cleaned and painted. Pull cords did not have protectors on. These were dirty on the ends and did not promote safe infection control within the home due to the risk of spreading infection. We spoke with the registered manager about this issue and they told us they would complete a review. The home had a separate staff team to complete the cleaning.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. Medications which needed to be administered within specific times were not always administered within the prescribed timescales. However, there was no evidence of impact on people. We reviewed controlled drugs stored in the home. We found a discrepancy in stock counts. Records showed controlled drugs had been signed out of the home and disposed of, however we found stock to still be present in the home. Where people were prescribed ‘as required’ (PRN) medication for anxiety, staff had not recorded the reason for administering this medication. This meant people were at increased risk of being administered medication when it was not required. We raised this to the registered manager who told us they would raise this concern with the staff team and put monitoring in place. Where a person was prescribed a nutritional supplement drink, this was not stored appropriately or safely. We saw a nutritional supplement drink had been opened. However, there was no recorded date of opening and the drink was found at the back of a shelf in one of the kitchens. This meant the person this was prescribed for was at increased risk of becoming unwell if they consumed this drink. The home had nurses who administered medication in the home. Staff were trained and competency assessments were completed.