Bright Meadows

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. 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 the safe management of people’s medicine.

This service scored 62 (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.

Accidents and incidents had been managed appropriately and in line with policy, with records kept detailing actions taken and outcomes. For some incidents, root cause analysis had been completed. This is a process which helps analyse what has happened, and looks at potential reasons and contributory factors, with the aim of identifying actions to help prevent a re-occurrence. Additionally, lessons learned documentation had been completed to consider any learning from incidents or accidents and if anything could be done differently moving forwards.

The complaints process was on display around the home. There was also a file explaining the process in reception next to where relatives signed in when visiting. The majority of people and relatives we spoke with had not needed to complain but told us they would speak to a staff member or manager, if they had any concerns. Complaints received had been managed in line with the provider’s policy. Complaints had been acknowledged in writing, meetings held with the complainant where necessary, outcomes of investigations shared and a written apology provided, where any shortfalls in care had been identified.

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

Information about people’s needs, as well as details about their likes, dislikes and how they wanted to be cared for, were collated within a booklet, often referred to as a ‘hospital passport’. People had taken these with them when attending hospital, to support continuity of care. Where people had transitioned between different care services, for example moving into Bright Meadows from another care facility, care plans and risk assessments had been shared between the different providers, again to ensure continuity of care and ensure the person’s needs could be met.

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.

People received safe care which met their needs. People and relatives spoke positively about the care provided. Comments included, “I feel very safe here” and “[Relative] is very safe in here; they would tell me if there was anything wrong. We cannot fault it.”

Safeguarding concerns had been reported in a timely way to the local authority, in line with guidance. Documentation within the provider’s safeguarding file, detailed actions taken and outcomes. Documentation confirmed the provider was open and transparent in reporting and allegations of abuse. Where possible, actions had been taken prior to safeguarding alerts being raised; to keep people safe and reduce the chance of the same thing happening again.

Deprivation of Liberty Safeguards (DoLS) are a legal framework designed to protect people who lack capacity to consent to their care arrangements, and ensure any deprivation of their liberty is necessary, proportionate, and in their best interests. Providers are required to submit DoLS applications to the local authority where people lack capacity and are being deprived of their liberty in some way, for example, not being able to leave the care home without support. DoLS applications had been submitted timely where required. Individual logs were in place on each unit within the home to help with monitoring applications and expiry dates.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. However, risk assessments and related care records had not always been updated in a timely way, to ensure people’s abilities were clearly documented.

Some people’s care records and risk assessments contained conflicting information, which meant it was not always clear what their current abilities were. For example, one person was immobile and required a hoist for all transfers to and from bed and into a wheelchair. However, one section of their care records stated they mobilised independently, using handrails and furniture to help them get around. We discussed this with the provider who admitted this section had been overlooked when the person’s needs had changed and the care plan updated. The care record was amended between our 2nd and 3rd site visits. The provider also arranged for all care plans and risk assessments to be checked for clarity and consistency.

People’s care records contained a mix of generic and individual risk assessments, covering areas such as skin integrity, nutrition, oral health, mobility, falls and choking. Where people had risks specific to them, for example, becoming agitated and aggressive during personal care, personalised assessments had been drawn up, to help guide staff on how to provide this aspect of care in the safest way possible.

Where possible, the provider supported positive risk taking, for example supporting a person at risk of wandering, to attend the local shop and other community locations, as being out and socialising was important to this person.

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

Safety checks had been completed with certification in place, to confirm utilities and equipment were safe to use. Portable appliance testing was up to date and equipment had been serviced as required. Regular fire safety checks and fire drills had been completed. A fire risk assessment had been completed in August 2025 with some remedial actions requiring completion by December 2025.An action plan was in place for this and being worked through. A legionella risk assessment was in place and water temperatures had been regularly checked.

People were cared for in safe environments, designed to meet their needs. The home was spacious, with private bedrooms, en-suite bathrooms, large lounges, and several communal dining areas. Corridors were wide and free from clutter and people had emergency evacuation plans in place. There were 2 elevators in place, which had been assessed as safe to use.

The provider completed internal audits for housekeeping. The maintenance lead completed daily, weekly and monthly checks of the home. We reviewed the monthly housekeeping audits which showed good compliance.

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 robust and safe recruitment practices to make sure all staff were suitably experienced, competent and able to carry out their role. Application forms were fully completed, and references had been obtained prior to starting work. UK disclosure and barring service (DBS) checks had been completed to ensure staff were of suitable character to work with vulnerable adults. Interview question and answer forms were kept on file and any historical gaps in employment had been explored.

Staffing levels were based on dependency with the provider using a system, which determines how many staff are needed to meet people’s daily care needs. The majority of people and relatives we spoke with, told us enough staff were deployed to meet needs and keep them safe. Overall, staff said the same, although some commented on sickness and/or absence impacting on this. The provider either used existing staff or agency to cover shortfalls caused by sickness of annual leave.

Staff received training in topics necessary to provide safe and effective care and meet people’s needs. Completion rates for the majority of topics was 95% or above. A detailed induction process was in place for new staff, to ensure they understood the role and felt confident to safely provide care to people.

Staff received supervisions and annual appraisals and told us they felt supported. Topics discussed included an understanding of the job role, a review of the past year, any achievements, goals for the coming year and workloads. Although supervision was held, the frequency of meetings varied across the staff team. Some had only completed 1 supervision so far in 2025, whilst others had completed 2. The providers updated policy stated meetings should be held quarterly, which was not currently being achieved. The provider was aware of this and had plans in place to ensure compliance.

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. People were protected as much as possible from the risk of infection because premises and equipment were kept clean and hygienic, and there were no offensive odours.

Domestic staff completed daily and weekly cleaning schedules which were signed and dated to show they had been completed. Each unit of the home maintained similar records which identified daily, weekly and periodic cleaning tasks. Records also identified when people’s rooms had been deep cleaned.

The provider completed internal audits for infection prevention control (IPC), and a leader completed a daily walkaround of the premises which included checks of IPC. There was an up-to-date policy on the control of infection, which staff could refer to if needed. Staff were trained in and had access to personal protective equipment (PPE). We observed staff wore PPE, when applicable, to help prevent the spread of infection.

The home had recently received a food hygiene rating of 5, which is the highest possible score.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

A system was used to alert staff when stock levels were low. However, this was not always effective. Records showed 6 people had missed between 1 and 10 doses of their prescribed medicines over the past month, because there was no stock available. This placed their health at risk of harm.

When medicines were prescribed to be taken when required or with a choice of dose, written guidance had been put in place for staff on how to give any medicines prescribed in this way. However, the quality of this guidance was variable and did not always contain enough information about how to assess people’s need for the medicine or how to select the most appropriate dose. This meant these medicines were not always safely and consistently administered.

When people needed to have their medicines covertly, such as hidden in food and drinks, guidance had been sought from the pharmacist about how to give covert medicines safely. However, staff did not always follow this guidance, which meant people may not have received the correct dose of their medicines, placing their health at risk.

A system had been introduced to prevent doses of pain relief from being given too close together. However, this system had not been extended to include all time sensitive medicines. As a result, we found some medicines had not been given safely, as not enough time had been left between doses.

Improvements were needed with how the application of transdermal patches was documented. Transdermal patches are medicated adhesive patches that are placed on the skinand deliver a specific dose of medication through the skin and into the bloodstream. The provider used an electronic system, often referred to as an eMAR system, to record the administration of medicines, including patches. The system had a small body map for recording where each patch had been applied. However, due to the number on entries on the body map, it was not always possible to tell where the next patch should be applied, to ensure it was done safely and in line with guidance.

Diabetes was not always managed safely. Staff did not always record people’s blood sugar levels on the eMAR system and there was no record of what people’s safe blood sugar range should be. Keeping blood sugar levels within a safe range is important to avoid long term health complications.

How changes to people’s medicines or doses was managed was inconsistent; one person’s dose changes had been safely implemented but another person was given a medicine after it had been discontinued by the doctor.

Staff demonstrated they understood how to use the eMAR system and each person’s medicines records included details of any allergies. Where people required thickening powder adding to their drinks, due to problems with swallowing, this had been documented correctly and given in line with people’s individual prescription.