Bradley Complex Care

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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 regulation relating to good governance.

Requires improvement: This meant the service management and leadership was inconsistent. Not all support staff felt respected, supported and valued. Governance processes did not always operate effectively. However, leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Risk was managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected analysed data about outcomes and performance. They used this to identify improvements.

We have not awarded this service a score for Well-led.

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

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on equity, equality, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The service had a new leadership team, and positions such as the hospital manager, forensic psychologist and occupational therapist had been in post between 5 and 14 months at the time of our inspection. The leadership team were working with frontline staff to develop a positive culture, with clear vision and values that applied in the work of their team. Leaders and managers were engaging with staff, people who use services, relatives and other stakeholders.

Leaders and managers told us staff were being given the opportunity to contribute to discussions about the strategy and improvements for their service. We spoke with 19 members of the staff team and the hospital manager who spoke about improvement plans for the service. Some staff felt able to raise concerns and highlight areas for improvement and this was acknowledged and supported, however some staff told us they feared reprisals if they raised concerns.

We spoke with the hospital manager about closed cultures as we know that closed cultures may lead to breaches of human rights including abuse or significant harm. The service undertook several actions to minimise this risk including being open and transparent regarding safeguarding and endeavouring to create a safe environment which was free from neglect and abuse. The service undertook regular reviews of CCTV. The service implemented regular incident reviews and reviews of concerns and complaints and discusses lessons learnt and changes or improvements that can be made to reduce and action these. The service was scheduling psychological formulations for all people who used the service to inform risk assessment and risk management planning.

External partners and relatives that we spoke with told us they were able to raise any challenges they encountered or concerns they had, and this was met with understanding.

Leaders and managers could explain how they were working to deliver care within the budgets available and the hospital shared with us their project plans for some service redesign, including creating more individual apartments and a central kitchen.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. Leaders had a good understanding of the hospital. They could explain clearly how the teams were working to ensure good care and discussed improvements being made to improve outcomes for people who use the service.

Leaders were visible in the service and approachable for people and staff. Staff received handovers, regular supervision sessions and access to training and development opportunities.

We scored the service as 2. The evidence showed some shortfalls. People did not always feel they could speak up and that their voice would be heard.

Staff we spoke with knew how to raise concerns; however, some staff told us that they had raised concerns but did not feel these were acted upon appropriately and some staff felt they could not raise concerns for fear of reprisal. However, we reviewed documentation in relation to complaints, incidents, safeguarding concerns and staff performance and we saw evidence that these issues were dealt with appropriately and efficiently.

The last staff survey was undertaken between 29 September and 12 October 2025 and it had a 36% response rate. There were questions asked in the survey regarding being able to ‘speak up’ and share concerns without fear of retaliation and 48% of respondents answered yes to this question. Whereas 59% of respondents had confidence in senior leaders to make the right decisions.

Other members of the team we spoke with felt leaders were supportive and approachable. Staff were aware of the whistleblowing policy and procedure in place. Staff had access to a freedom to speak up guardian and staff we spoke with knew how to contact them and who they were, but some staff did not feel as though they could. The hospital told us following our assessment that they had invited the speak up guardian to visit the service in April 2026.

People and relatives told us they had opportunities to give feedback on the service they received in a manner that reflected their individual needs.

People, staff and relatives could meet with members of the provider’s senior leadership team and governors to give feedback. The provider informed us that they had implemented an action plan based on the results of the staff survey, we saw that there had been a lot of comments regarding what the organisation was doing well and what the organisation could improve on.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Equality and diversity were actively promoted. The staff team included a wellbeing lead, and the hospital was looking to provide a staff wellbeing representative on all shifts to support the team through raising awareness of wellbeing activities and initiatives, promoting healthy lifestyles and positive mental health. The service had a dedicated multifaith room which all staff could use.

Most staff we spoke with told us they were supported with reasonable adjustments or flexible working arrangements to support them to carry out their role and to account for personal circumstances, where relevant.

Elysium Healthcare had a diversity group in place to support services and contributed to policies. The hospital manager was part of this group. The provider also advertised a free phone line for staff to enable them to raise concerns regarding equality and diversity.

Staff had the appropriate training in equality and diversity and at the time of inspection, staff training compliance was at 99%.

The last staff survey was undertaken between 29 September and 12 October 2025 and it had a 36% response rate. There were 3 questions asked in the survey regarding experiencing discrimination at work and the response was positive in terms of managers and work colleagues an average of 13% answered yes, whereas the question regarding experiencing discrimination from patients was higher at 44%. The service was tackling this by inviting the police to undertake a session for people using the service regarding using kind words and explaining hate crime. The police had sent through resources which were reviewed to ensure they met the needs of the people using the service.

We scored the service as 1. We scored the service as 1. The evidence showed that some governance process did not always operate effectively. However, the service did have clear responsibilities, roles and systems of accountability. They did act on information about risk, performance and outcomes.

Our findings from other key questions demonstrated that some governance process did not always operate effectively.

Medicines management systems were not always effective, there was duplication of records, missing entries and we found missing protocols and information regarding an allergic reaction which did not support safe practice. 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. The provider said they would review this.

Staff undertook or participated in local clinical audits; however, some audits were not always sufficient in providing assurance such as audit of health action plans, mental health act administrative audits and audits and monitoring regarding infection prevention and control to ensure staff used the correct PPE and adhered to guidelines.

Freedom to speak up processes were not integrated effectively within the service. Some staff we spoke with told us that they either did not feel like their concerns were listened to or acted upon or they feared reprisal from speaking up. Staff had access to regular supervision sessions, however raised concerns regarding confidentiality of their supervision notes.Following our assessment the hospital informed us that they understood their process was in line with data protection. We reviewed the organisations Clinical Supervision policy which we noted was out of date with a review due in March 2025..

Systems and processes for communication with external providers and families required some improvement. Families told us about difficulties contacting the service, changes that had been made to attendance at monthly independent care reviews and discontinuation of an online weekly update, however this was reintroduced when the family told the hospital this was helpful and the hospital confirmed these weekly reviews were sent to family members. The service also planned friends and family events to support communication. External partners also told us that they ask for minutes of meetings, evidence or specific reports but these did not arrive in a timely way or they had to request them more than once.

However, there was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of people using the service.

Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required.

The service had business continuity plans in place for emergencies.

The service used systems to collect data from wards and directorates that were not over-burdensome for frontline staff.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care. Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and person-centred care.

Information governance systems included confidentiality of care records. Information was in an accessible format, and was timely, accurate and identified areas for improvement.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The hospital had good working relationships with external providers such as adult social care, safeguarding, independent health advocate and future care providers. We received feedback from 4 external partners, who provided us with some positive feedback, and they told us about collaborative working to support people who use the service. The advocate informed us that the service are transparent and shared relevant information such as outcomes of safeguarding referrals and received in depth updates on every person when on site.

Directorate leaders engaged with external stakeholders such as the care quality commission, commissioners and Healthwatch.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The organisation had established a research development group who were reviewing learning disability and autism research papers and documents, how they apply to services and how their service can benchmark against good and best practices.

The service was planning on and undertaking several environmental changes to best support the needs of the client group. This included creating a central kitchen to reduce the issues and problems that the service encounters, improve weight management, ensure meals are prepared in line with care plans and meet nutrition and dietary requirements. The service was also planning to adapt the current apartments and create more single accommodation to best meet individual needs and remove challenges with shared accommodation and reduce safeguarding concerns. Plans and budgets had been agreed for this work.

We spoke with the speech and language apprentice who was the quality improvement champion. This member of staff was running a project to aim to reduce incidents through effective communication. The service had been implementing small changes and measuring how this was affecting change. Some changes included reinforcing communication books, incorporating Makaton and increasing staff confidence in its use by regularly discussing it in morning handovers and checking staff understanding.

The forensic psychologist had undertaken a piece of trauma research which was based on a trauma informed approach to staff wellbeing. There had been several recommendations from the research and there was support from the organisation and hospital to embed these. These included:

• Weekly reflective practice for staff and this has commenced (previously monthly)
• Harness staff expertise and lived experience to create wellbeing groups. There were plans to form a committee for a more diverse staff team and create an offer to meet individual needs.
• Additional training for staff
• Offering wellbeing sessions
• Creating a more inclusive environment, recognising the diversity of staff, exploring and accepting culture and enabling staff to feel comfortable in their own identity.