Bromley Place

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.

This is the first assessment for this registered service. This key question has been rated good.

This meant people were safe and protected from avoidable harm.

This service scored 72 (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.

The service demonstrated a well‑embedded learning culture, actively seeking feedback from people and using this to drive improvements to care and communication. The service also proactively gathered feedback from relatives and external professionals, ensuring insights informed ongoing development. Processes were firmly in place to learn from safety incidents, supported by tools to report, record, investigate and analyse events. Minutes of meetings evidenced learning was routinely discussed and shared in both team meetings and senior leadership meetings.

The management team were proactive in responding to feedback from CQC, implementing improvements in areas such as medicines protocols and safe recruitment practices. The provider reviewed feedback and ensured relevant changes were introduced promptly. We were told by the Operations Manager learning was shared across the wider organisation to support the development of other services within the provider group.

Robust systems supported ongoing staff training, with structured monitoring to ensure all staff maintained up‑to‑date skills and competencies. Staff shared with us how they completed role play scenarios within their supervisions which supported their learning and development.

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.

People were supported to safely transition into the service through individualised and well‑planned approaches. This included pre‑admission assessments and multiple visits to the service, enabling people to meet staff and other individuals living there. These steps helped promote familiarity and reduce anxiety during the transition process.

Effective communication systems were in place to support people when moving between services. Key information documents were available, ensuring other professionals had access to essential details needed to keep people safe and maintain continuity of care.

These systems demonstrated a proactive and person‑centred approach to managing transitions, supporting people to move safely and with minimal disruption.

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.

Safeguarding concerns were raised with the local authority when required, and statutory notifications relating to safeguarding alerts were submitted to CQC in line with reporting requirements. The service had a safeguarding policy in place which outlined actions staff should take when abuse is suspected or disclosed.

A review of the training matrix showed all staff had completed the relevant safeguarding training. This indicated staff had received the necessary guidance to recognise and report signs of abuse or neglect. A staff member told us, “We have specific training before we are signed off, we must pass them before we are signed off.”

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.

People were supported to take part in a range of community-based activities, including football, visiting local shops and amenities, attending church, and attending day trips such as visits to the zoo. Individual weekly activity planners showed activities were planned around individuals’ preferences and interests, promoting choice and independence. People told us they enjoyed taking part in activities within the local community.

Risk assessments were in place to support people to engage in these activities safely. These were detailed and person-centred, outlining the specific support people required. Staffing levels were arranged to meet each person’s assessed level of need, ensuring people could participate in community activities safely and confidently.

The service demonstrated a positive approach to enabling people to take part in meaningful activities while effectively managing associated risks.

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

The environment was clean, tidy, and free of clutter. We did not identify any concerns regarding fire safety, and records showed facilities and equipment were maintained and serviced in line with required schedules. Individual flats were clean, and appropriate window restrictors were in place to promote safety.

A window restrictor was found to be broken; this was identified prior to our assessment and raised for repair. This demonstrated a responsive approach to environmental risks.

The provider ensured there were enough experienced and trained staff to provide safe care and support. Recruitment processes and procedures were in place and were generally followed to keep people safe. However, we identified one shortfall in safe recruitment practices. One staff member’s Disclosure and Barring Service (DBS) check had not been reviewed against the adult barred list. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. This presented a potential risk to people using the service, and this issue had not been identified through the provider’s internal auditing systems. Once this concern had been highlighted, the provider took prompt action to complete the required checks and implemented a risk assessment to ensure people’s safety in the interim. The provider told us they planned to review all staff files to ensure there were no further inconsistencies.

There were enough staff to meet people’s needs; all staff had completed a through induction, and systems were in place to ensure ongoing learning and skills development. Staff were supported through regular supervisions and team meetings. Staff we spoke with all shared how the registered manager was approachable and supportive of them, and they felt able to raise concerns or request advice.

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 service demonstrated safe infection prevention and control practices. During our visits we observed staff wearing appropriate personal protective equipment (PPE) when supporting people within their personal spaces, in line with current guidance. Staff had completed infection prevention training.

The environment was clean, well maintained and free from clutter. People’s flats were in good condition; and staff encouraged and supported people to keep their living space clean.

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.

We found protocols relating to ‘as needed’ medicines (PRN) did not clearly outline the circumstances in which PRN medicines should be administered, nor the actions staff should take if PRN medicines were required over an extended period. The provider took prompt action to update the PRN protocol documents to ensure they included clear guidance on when to administer PRN medicines and how to monitor ongoing use.

We identified issues relating to medicines with expiry dates upon opening. Ear drops that should have been discontinued after the recommended period were still in use. The storage box had been dated when opened, but an expiry date had not been recorded. This presented a risk of people receiving medicines beyond their safe usage timeframe.

Additionally, some medicine administration records (MAR) charts did not clearly document administration instructions for specific medicines. Although this information was available on medicine labels and in the medicines overview documents, MAR charts failed to contain detailed and accurate instructions to support safe administration. This was rectified onsite following a discussion with the pharmacist.

While the provider took immediate steps to address the concerns raised, these issues indicated improvements were needed in ensuring medicines documentation and monitoring systems were consistently effective.

Medicines were stored correctly and securely, and people received their medicines as prescribed. PRN protocols and MAR charts were kept together with medicines in a locked cabinet within the office.