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 69 (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.

An accident and incident recording system was in place. Actions taken following events were recorded, including when other health professionals were called or the local authority safeguarding team informed. Records and information about incidents were reviewed by the management team. Where lessons had been learned the sharing of these was done in staff handovers and meetings.

Families and relevant others were informed of accidents and incidents, and the duty of candour was followed.

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

Preadmission assessments were completed and transitions into the service were well planned. The planning usually included family and professionals who were already involved in the care and treatment of people.

People and their relatives told us they had been involved in informing and developing care plans. Processes were also in place to help ease transition to other services if needed such as detailed emergency hospital admission information.

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.

People and their relatives told us they felt the service was safe. Incidents of safeguarding had been identified and shared with the local authority.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and found consents had been obtained and if appropriate DoLS authorisations applied for. Staff had completed training in safeguarding and the MCA.

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.

Risks associated with people’s care and treatment had been recognised and recorded. Records were detailed, accurate and current. Management had systems for the oversight of accidents and incidents, trends and themes. People’s needs were regularly being reviewed and were reflective of changing needs.

A relative told us, “Staff managed [Relative] really well and know just what they need.” Staff told us they felt they had received the right training to meet people’s needs safely.

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

Regular environment, equipment safety checks and regular servicing of equipment was in place. There was an ongoing programme of maintenance to the home. However, we found regular fire evacuation drills had not been completed in the last 12 months. When this was identified the interim manager immediately responded by completing them.

The provider did not always make sure all checks of suitability for working in the home had been completed. They made sure there were enough qualified, skilled and experienced staff. who received support, supervision and development.

Some checks of suitability had not always been completed in line with the requirements for fit and proper persons employed. We checked the files of 3 staff employed and all of the agency staff currently working in the home. The checks of suitability for agency staff working in the home had not always been completed prior to working in the home. The interim manager took action and completed these checks.

Most training was completed via eLearning with some face to face and skills competencies were completed for some aspects of training. Staff felt they had received sufficient training to care for people safely. Staff very supported by the management team especially since the interim manager had been in post. Staff supervisions had not always been completed as regularly as per the provider’s policy and the interim manager had recognised this. They had prioritised annual staff appraisals and implemented a plan to bring supervision frequency in line with the policy.

There were enough suitably qualified staff on each shift. Staff told us they felt there were sufficient staff to keep people safe. People told us they felt staff had sufficient training, a relative said, “Definitely trained to do what can be a difficult job.”

Infection prevention and control

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 home was clean and regular checks of the cleanliness and infection prevention were being completed. Personal protective equipment (PPE) and hand sanitiser was readily available and seen to be used effectively. People were happy with the quality of cleanliness in the home. One person told us, “They [staff] keep everywhere clean.” Food handling and hygiene was done in line with best practice.

The provider did not always make sure topical medicines were stored safely or staff had their competencies in administration checked. Medicines and treatments were administered safely and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Some prescribed topical medicines kept in people bathrooms were at risk of overheating and no monitoring of temperatures was in place. This was immediately addressed by the management team. Temperature checks of the medicine room and fridge were not being consistently recorded due to new recording systems being introduced. We saw that where an action on an audit had been identified this had not been completed in a timely manner but was addressed immediately by staff.

A representative from the GP surgery carried out a weekly ’ward round’ at the home. Medicine records were clear and concise in detailing peoples’ preferences for the administration of their medicines. A number of people were appropriately supported in administering their own medicines.

Permanent staff had completed medicines training and had their competency assessed. However, not all the agency staff responsible for medicines during their shift had been assessed in the home as having the right competencies but had received medicine training. The interim manager acted and checked their competencies.