New Bradley Hall

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.

Systems were in place to review, analyse and learn from incidents, accidents, safeguarding and complaints to drive improvements in the home. Incidents were reviewed by management and the provider to ensure actions were taken where needed to mitigate future risks. Any learning from incidents were shared internally with the staff team. A staff member told us, “Information is shared during handovers or in team meetings on how we can improve things or if we need to do things differently.”

However, we did find some incident records which had not been signed off within a timely manner and all actions completed. This feedback was shared with the management team who were receptive to this feedback and took immediate action to address this and complete the required records.

Audits were completed and all incidents including complaints and safeguarding concerns were analysed for patterns and trends.

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 and relatives told us they were involved in the transition process when people moved into the home. Staff worked with health care partners where needed to facilitate people’s safe move into the home. One relative said, “[Person] came in from hospital, so arrangements had to be made, and the staff helped us with this, so it went smoothly.”

Staff ensured communication between agencies was maintained and any key information was shared when people were supported by different services. This included where appropriate key information contained within a ‘hospital passport’ and peoples respect forms. This ensured people received continuity of care.

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 told us they felt safe when being supported by staff. One person told us, “I don’t like the hoisting business, but I feel safe with the girls.” Another person said, “The staff are lovely they help me keep safe by walking with me.” Relatives and friends, we spoke with also confirmed they felt assured people were being supported safely.

Staff and the management team knew the procedures to follow if they had any concerns about people and if they saw any warning signs that may suggest a closed culture was developing. (Closed cultures are where people may be at risk of deliberate or unintentional harm, and people are not listened to.) A staff member told us, “If I had any concerns, I would report it straight away and then go higher if I needed to. There is information in our staff room about the process, and I have had the training, and we often discuss the procedures in meetings.”

The registered manager understood how to respond to concerns, and notifications were shared with relevant agencies where needed.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, this is usually through MCA application procedures called DoLS. Systems were in place to maintain oversight of all authorisations in place to ensure they were lawful and in people’s best interests.

Although staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them, records did not always underpin this practice.

People had a variety of risk assessments in place applicable to their individual needs. We found the majority of these had been reviewed and updated in response to changes in needs. However, we found a couple of occasions where this was not the case. For example, we found one person had experienced a choking incident, but their choking risk assessment had not been updated to reflect this and the actions taken to reduce the risks. Another person had showed signs of being distressed but their risk assessment and care plan had not been updated to reflect how this was displayed and actions for staff to be aware of. On all occasions we saw from other records actions had been taken in relation to any new risks identified and information had been shared with staff during handovers, so they were aware. These shortfalls were raised with the management team who were receptive to this feedback and took immediate action to address this and complete the required changes.

The home supported people living with dementia. Staff we spoke with understood there were times when people may become distressed. Staff were able to tell us what steps they took to understand and to support people to express their emotions. People who liked to move around the home were able to do so with clear risk assessments and strategies to maintain their independence and dignity. A relative told us, “The staff are aware of the risks and procedures are in place to support [person]. I was consulted about these and agreed with them.”

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

People told us the home was well maintained, and any repairs were completed in a timely manner. One person told us, “Everything works well and if anything needs fixing the ‘repair man’ comes in and gets straight to it and fixes it.”

The home had been designed following best practice. There was natural light and wide corridors, to help people to safely navigate to and from their bedrooms. People had access to an external garden which was paved and had seating areas. However, some areas needed attention due to being overgrown. The management team told us this was part of an action plan to improve this area.

The home had a maintenance person who undertook repairs in a timely manner and completed safety checks such as checking window restrictors, water temperatures, and fire doors.

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.

People and relatives told us overall there was enough staff to meet their needs. One person said, “The staff are very good they do come quickly when I use my call bell. Sometimes I may have to wait a little longer at busier times like in the morning.” Another person told us, “I’m not one to moan but I would like more attention staff are nice just always busy.” A relative said, “Staff are fantastic and know [person] so well sometimes agency is used but the home uses the same company for continuity.” We received mixed feedback from staff some of whom told us at times they felt rushed due to complexity of some people’s needs.

We observed people’s needs were met by enough staff on each unit we visited. There were occasions during busier times on some units where staff roles were task focused due to the demands of the unit. We also observed key times such as when a staff member finished duty after lunch where staffing levels reduced for half an hour until the afternoon staff started their shift. This meant on 1 unit some people were delayed during this time moving from the dining room table back to their choice of seating.

We shared our observations with the management team and provider who agreed to revisit the dependency needs of people to ensure sufficient staff were deployed to meet people’s needs.

People were supported by staff who had been recruited safely. We found all required recruitment checks had been completed before staff commenced employment in the home. Staff were provided with an induction which included shadowing opportunities. Training information demonstrated staff had completed all core training suitable for their role. This included training to support people living with dementia and to meet people’s communication needs.

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 told us they were happy with the cleanliness of the home. One person said, “My bedroom is always kept cleaned. The rest of the home is too. The domestic staff have high standards. There are no smells here.” A relative told us, “The home is always clean and tidy.”

We observed the home to be clean in all areas. Domestic staff were deployed across all 3 units of the home and completed cleaning schedules to record the areas they had cleaned. Discussions with domestic staff demonstrated they had received training and had sufficient equipment to clean the home effectively.

Although the provider made sure medicines were safe and met people’s needs, and preferences, some improvements were needed with the management of as required medicines.

Records demonstrated medicines prescribed for use ‘as needed’ (PRN) were not always administered in accordance with guidance. For example, we found for some people their PRN had been given routinely each day for a period without this being escalated for review. For 1 person this included a medicine to reduce distress. In addition, we found records for PRN administration did not always give a clear rationale for administration particular those administered to people who became distressed. Records did not always state what alternative techniques has been used before medicines were administered. We also found some people’s risk assessments and care plans had not been updated in response to changes or risks associated with their medicines. We raised these issues with the management team who were receptive to this feedback and took immediate action to address this. Guidance was sought from the advance nurse practitioner (ANP) and records were updated. In addition, the provider completed a full PRN audit, and an action plan was put in place to improve the systems in place. This included a new PRN escalation process.

People told us they received their routine medicines as prescribed. One person said, “The staff help me take my tablets and they are always on time.”