Bradley Complex Care

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

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 changed to requires improvement. The service was in breach of the legal regulation relating to safe care and treatment.

Requires improvement: This meant some aspects of the service were not always safe. There was an increased risk that people could be harmed. The service did not use systems and processes to safely record and manage medicines. The service did not always follow infection prevention and control guidelines. However, staff assessed and managed risks to people and themselves. Staff understood how to protect people from abuse and the service worked well with other agencies to do so.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 3. The evidence showed a good standard. The service had a positive culture of safety. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to identify themes and trends, identify improvements and embed good practice.

The service informed us that they recorded all incidents and accidents on the organisation’s online incident reporting system which were monitored at service level. The hospital had governance systems in place, including assurance and auditing processes. Leaders of the service spoke with us about monitoring themes and trends of incidents, and we observed 2 individual care reviews during the inspection which were attended by a multidisciplinary team. During these reviews, incidents were discussed, and the team examined the timing of the incidents and reasons and what could be done to mitigate this in terms of individual needs, staffing or additional activities.

We reviewed incident data and from January to December 2025 the hospital recorded 3900 incidents. The incidents reported included aggression and violence (66%), self-harm (13.5%), environmental (9%) and health related (5%) incidents. Staff were encouraged to report all incidents which were discussed during morning meeting, directly after handover and reviewed in individual care reviews. Both meetings had a multidisciplinary focus. We saw evidence that the service were supporting people to reduce these incidents by collaborative care planning and undertaking quality improvement initiatives.

The service used audits to review the number of incidents and any use of restraint and discussed this as a team to identify trigger points and make positive changes. The provider had a Use of Force Act policy in place aimed to reduce the use of force and ensure accountability and transparency. The service implemented the Patient Safety Incident Response Framework (PSIRF) which sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. Any incidents that meet these criteria are investigated, reports completed and sent to central PSIRF team for review before being sent to other interested parties.

All staff we spoke with told us they knew what incidents to report and how to report them.

Staff understood the duty of candour. They were open and transparent and gave people and families a full explanation, if and when things went wrong. Families we spoke with confirmed that the service contacted them if an incident had occurred.

Staff we spoke with confirmed that they received feedback from investigation of incidents, both internal and external to the service. The service discussed immediate learning from incidents in handovers and themes and trends as part of team and leadership meetings. Staff we spoke with told us that the ward’s debrief process following an incident and opportunities for reflective practice were good.

We scored the service as 3. The evidence showed a good standard. The service 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.

The service’s referral and admission processes ensured that all essential information, about the person, was received to determine if the persons needs could safely be met.

Staff involved all the necessary healthcare and social care services to ensure people had continuity of safe care, both within the service and post-discharge. As several people in the hospital were out of area, the service collaborated with and had links with external partners. Such as the host commissioners (this is the Integrated Care Board (ICB) responsible for overseeing and monitoring the quality of care for individuals with learning disabilities and autism) and teams from the person’s home area.

The hospital involved people using the service in their discharge planning and worked with future providers to support transitions of care. One person we spoke with told us, ‘They were excited for a change as they get to meet new staff and that the staff come to the service to spend time with him and get to know him.’

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

Staff were trained in safeguarding adults and visiting children, and staff were 97.6% compliant. The hospital had a safeguarding lead who had completed additional training. All staff we spoke with could give examples of how to identify risks and protect people from harm.

Staff knew when to escalate concerns and how to make a safeguarding referral. Between January and December 2025, the hospital had logged 169 safeguarding adult incidents on a log sheet, this data detailed a summary of the incident and the action taken. This safeguarding adult’s log sheet was emailed to the local authority safeguarding adults’ team at the end of each month.

We reviewed blanket restrictions register for the hospital. The hospital listed several individual and blanket restrictions. The blanket restrictions included locked cupboards in the kitchens including a restriction on sharp items, limited access to laundry facilities, limited access to occupational therapy kitchen, activity room and sensory room, garden gates are locked and child locks used on company vehicles. The register also tracked the reasons put in place due to risks or safety concerns. Individual restrictions were care planned and regularly reviewed.

Mental Capacity Act

Staff received training in Mental Capacity Act and the Deprivation of Liberty Safeguards, staff training was at 96%. The provider had a policy on the Mental Capacity Act, including Deprivation of Liberty Safeguards. Staff were aware of the policy and had access to it.

Staff we spoke with had a good understanding of consent, including in relation to the Mental Capacity Act. People were supported to communicate and make decisions to enable the service to deliver person-centred care and treatment in line with people's best interests.

There were no deprivation of liberty safeguards applications made in the last 12 months, these would be made to protect people without capacity to make decisions about their own care.

The service had arrangements to monitor adherence to the Mental Capacity Act.

Staff audited the application of the Mental Capacity Act and acted on any learning that resulted from it.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to people and themselves well. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 6 care records and found that all people had up to date risk assessments and risk management plans in place.

The hospital focused on the least restrictive practice approach. Records showed the provider recorded 3,300 episodes of restraint between 01 January 2025 to 31 December 2025. We could see a reduction in incidents over the year and 18% of incidents were categorised with ‘friendly come along’ intervention technique and the most used technique at 28% was an ‘upper limb wrap’. The hospital had invested in a sensory chair to support with interventions. This chair simulated the wrapping of arms around a person as a care planned approach to meet people’s sensory needs. The staff referred to this within the individual care review as a 'cuddle chair'. The service also had the use of safety pods (furniture designed to assist with safe and supportive interventions).

Records showed that between 01 September and 30 November 2025 there were 60 incidents where supine (lying on the back, face upwards) was used but no recorded incidents of prone restraint during this time. All restrictive interventions were reviewed by a multi-disciplinary team and analysed monthly through governance and individual care reviews. Records showed that staff completed training on Safe and Therapeutic Management of Violence and Aggression (STMVA) and compliance at the time of inspection was 97%. Staff also completed conflict resolution and breakaway training, and staff were 95% and 94% compliant, respectively.

During inspection we reviewed 6 restraint records, we found these restraints were well documented, the incident reported appropriately, what deescalation techniques were attempted and the reason for restraint recorded. The person and staff involved in the restraint were offered a debrief and any physical health observations were undertaken following the restraint.

The service had recorded 58 uses of rapid tranquilisation between 03 February 2025 and 16 January 2026. We saw this was documented, physical health observations recorded, NEWS2 score documented and all uses were reviewed as part of the providers reducing restrictive practice trend report.

External partners we spoke with were aware of the levels of intervention and use of rapid tranquillisation. External partners told us that the “therapists have formulated clear recommendations for communication and sensory integration strategies”. Following this work, they expected to see a reduction of rapid tranquilisation use and strategies to inform care plans to be used in the community.

Staff involved people in care planning and risk assessment shown by evidence in care plans, participation in multidisciplinary team reviews and feedback from family members.

Staff communicated with people so that they understood their care and treatment, including finding effective ways to communicate with people with communication difficulties. The service had developed meeting preparation notes to enable people to record any feedback they wanted to give, or requests they wanted to discuss as part of their independent care review. We observed these being discussed during the 2 reviews we attended during the inspection.

Staff enabled people to give feedback on the service they received, for example, via verbal feedback, surveys or monthly community meetings.

Staff ensured that people using the service could access advocacy. We received feedback from the independent advocate who told us that the service ensures an office on site is available for the advocates once a week and advocacy are invited to attend all meetings including care programme approach meetings and tribunals.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The layout of the hospital provided 8 communal shared apartments and individual apartments in total and depending on the needs of the individual. During our inspection and our tour of the environment we entered all 8 apartments. 3 of the apartments had double occupants and the other 5 apartments had single occupants. All apartments had a varying number of staff depending on the needs and funding arrangements for each person. All apartments had a kitchen; this was either part of an open plan or a separate room within the apartment. Apartments also had an outdoor space. All apartments opened out onto a shared outdoor area, known as the cloister area. This area was sheltered but outside and open to the elements. The nursing office was based within this area which enabled accessibility. However, we observed people using the service waiting for their medication outside which we raised with the provider in terms of the persons privacy and dignity as part of the medication administration process. The provider informed us that they try to avoid this by seeing people at the clinic in turns so people are not waiting and some people’s medications are taken to their individual apartments.

We saw evidence that staff did regular risk assessments of the care environment. Where there were potential ligature anchor points the hospital mitigated the risks adequately.

At the time of our inspection the hospital complied with guidance on eliminating mixed-sex accommodation.

Staff had easy access to alarms and people using the service had easy access to nurse call systems.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The hospital had a comprehensive mandatory training programme and the overall compliance at the time of our inspection was 97%. The provider did not have a target for training and except for 3 courses all were above 90% compliance.

The service informed us that they had 17 FTE support workers, 2 full time nurses, 1 assistant psychologist, 1 speech and language therapist vacancies at the time of inspection. The hospital informed us a recruitment drive was ongoing for the support staff and nurse vacancies and interviews were scheduled for the speech and language therapist vacancy.

The hospital reported the average staff turnover rate over the last 12 months was 24.6% and sickness absence over the same period was 2.63%.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. When agency and bank nursing staff were used, those staff received an induction and were often familiar with the hospital.

Staffing levels allowed people using the service to have regular one-to-one time with their named nurse. There were no recorded instances of staff cancelling escorted leave or ward activities due to staffing levels. There were enough staff to carry out physical interventions (for example, observations, restraint and seclusion) safely (and staff had been trained to do so).

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. They shared concerns with appropriate agencies promptly.

We observed that staff did not always adhere to infection control principles, including handwashing. During our inspection we observed support staff dealing with soiled laundry and although they were wearing gloves the staff did not have any other personal protective equipment (PPE) on. We observed support staff had false nails and were wearing jewellery. Support staff were also responsible for cooking and preparing meals, personal care and physical restraint. During an observed medication round nursing staff did not adhere to hand washing practices. During medication rounds, it is essential to perform proper hand washing to reduce the risk of transmitting microorganisms.

However, the organisation had a policy and standard operating procedure regarding Personal Protective Equipment (PPE), and these documents were in date and gave clear instruction. 100% of staff had undertaken infection control level 1 training. The hospital had regular audits in place to monitor adherence to infection, prevention and control. We fed our concerns back to provider and they provided evidence that they had emailed staff to remind them of their responsibilities after our visit.

Apartments appeared to be clean, and no concerns were raised by people using the service, families or external partners who regularly visited the service. Cleaning records were up to date.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date and stickers showed equipment had been calibrated, as required.

We scored the service as 1. The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

During our inspection we found several issues relating to defensible documentation and record keeping. We reviewed 6 medication records and 3 had missing entries. We reviewed 6 Health Action Plans, 4 had medicines which were out of date and 2 had medications missing. 3 out of 6 protocols for PRN (as needed) medication were not available. We also noted a medication allergy was missing on a person’s medication chart regarding a severe reaction to anti-psychotic medication. We were aware of recorded issues raised back to the provider from section 61 reports (Section 61 of the Mental Health Act requires providers to report certain events and certified treatment to the regulatory authority). We identified one issue during our inspection.

We reviewed charts for national early warning scores (NEWS) and found these were not consistent, for example one folder had 5 NEWS charts present but no corresponding dates. There were multiple recording sheets for some checks such as the intermediate life support bag and defibrillator check and there were multiple entries missing.

We were also informed of an incident regarding some missing medication. The service provided an explanation and told us mitigations were in place to prevent this from happening, such as ensuring there were 2 nurses undertaking medication rounds however during our inspection, we observed 1 member of staff completing a medication round. Therefore, we could not be assured that the mitigation and actions taken by the provider were adequate.

We fed these concerns back to the provider and asked for some immediate action to be taken with regards to the protocols and allergy information. The provider also provided evidence that emails had been sent to staff regarding removal of duplicated records and the NEWS2 chart had been amended to ensure it included dates, times and name and DOB of the person using services.

The service applied the STOMP framework (stopping over-medication of people with a learning disability, autism or both) effectively and we spoke with the responsible clinician regarding the reductions, changes to medication and the regular reviews in place which were in line with NICE guidelines.