Bradbury Gardens

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 75 (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 provider had, through their own systems, identified they were experiencing an increase in the number of concerns, incidents and feedback about the service. We saw these had been discussed openly, and comprehensive action had been taken to identify the cause and put in measures to improve practice and promote learning on an ongoing basis. The providers own systems had been effective in identifying learning and making positive change as a result. A service manager told us, “Things are much better now, although we know there are still things to do. Communication has improved, systems have improved, we're still catching up, but it's a great improvement. We are clear on our tasks and systems, we all want to achieve.”

To embed learning, the national lead of quality and safeguarding completed an annual report to review concerns, complaints and compliments for the preceding 12 months. The data from this report was used to generate themes and trends and proactively identify and manage any risks.

Identified areas of learning were routinely explored in routine multi-disciplinary team (MDT) reviews, staff meetings and debriefs. This meant safety incidents were appropriately investigated and reported. Risks were addressed promptly and treated as opportunities for continuous learning and improvement.

The head of risk and compliance prepared and presented a report to board 3 times per year. This report provided a detailed analysis of incidents, accidents and reportable events including themes and trends over a 12-month period. This process had recently been developed to improve oversight and accuracy of the reporting process.

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.

Safety and continuity of care was a priority throughout people’s care journey. There was a mixture of student accommodation and long term living at Bradbury Gardens, which had been well considered to meet people’s needs. The service worked with people and those close to them to establish their plan of care and comprehensive individual transition plans, prior to them moving between services. We saw examples of the extensive work to ease transition. This included the environmental adaptation of people’s new homes, introductory meetings, visits, staff shadowing and accessible guides. A relative told us, “I was involved in the initial assessment before my loved one moved in, it was comprehensive and thorough. This gave me the confidence that this was the right home for my loved one and I have not been disappointed. The attention to detail has continued”.

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 and their relatives told us they felt safe living at the service. A person told us, “Yes, yes staff look after me, staff are kind.”

Safeguarding concerns were tracked and reviewed, and lessons were learned on an ongoing basis. These concerns triggered care plan reviews, safeguarding referrals, liaison with professionals and updated risk assessments. This demonstrated the service was alert to risks of abuse or neglect and acted when concerns emerged.

The provider had up-to-date safeguarding policies and procedures for identifying and reporting abuse. These had been recently reviewed following a lesson learned exercise in response to a safeguarding incident. The provider undertook a robust review process, identified key learning, and implemented improvements to mitigate the risk of a similar occurrence and enhance safeguarding practice in the future.

Easy‑read safeguarding information was available, which supported people to recognise unsafe care, abuse, and routes for raising concerns. Easy‑read information refers to accessible text presented in a simplified format using clear language and supportive imagery.

Staff received regular safeguarding training and demonstrated strong awareness of how to recognise and respond to concerns. People were assured that if they ever raised a worry, staff would take prompt action to keep them safe. The safeguarding lead told us, “It has to be a collective culture where everyone understands their safeguarding responsibility.”

Staff told us they felt confident in recognising and responding to safeguarding concerns. They described how their regular training had strengthened their understanding of the different types of abuse people could be exposed to, and how this informed their everyday practice. Staff were clear about the actions they would take if they witnessed or were told about any concerns. They also expressed confidence in the registered manager and the individual management team, telling us they trusted them to act promptly on any issues raised.

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 how they managed DoLS within the service. We found the provider had applied to the local authority for DoLS authorisations where appropriate. The provider had a record of all DoLS applications that had been made, including details of any conditions to the authorisations.

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.

When people communicated their needs, emotions or distress, people were consistently supported in a positive way that protected their rights and dignity. People’s care plans reflected any foreseeable risks that might need restrictions, ensuring measures were always the least restrictive option possible. The provider employed positive behaviour support practitioners focuses to work specifically with people with emotional wellbeing support needs or distressed behaviour. Evidence-based interventions and strategies were used to minimise the need for restrictive interventions. De-briefing took place, and the service maximised learning for the future about the causes of people’s distress.

There was a balanced and proportionate approach to risk that supported people and respected the choices they made about their care. For example, we heard how staff had supported an individual with a rare healthcare condition, to minimise the impact and ensure the person was encouraged to take carefully managed risks in order to live a fulfilling life. A staff member said, “The team come together and work in collaboration [to meet people’s needs and preferences and manage risk; we always ensure if there are any concerns or issues around health that we report it immediately. Any concerns are then reviewed by the nursing team or the relevant professionals are contacted [in a timely way].”

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

The environment was well-maintained by a well-equipped site services team. The signage, the decoration and other adaptations to the premises helped to meet people’s needs and keep them safe. Environmental risk assessments had been completed on an ongoing basis to identify hazards and put measures in place to minimise identified risks.

The provider undertook a range of checks of the physical environment to help ensure they were safe for people. These included inspections and testing by suitably qualified contractors relating to fire safety, gas safety, electrical systems and water hygiene. The provider also completed regular health and safety assessments to help maintain a safe environment. Where recommendations had been made by external agencies, such as the fire service, the provider demonstrated a commitment to working collaboratively to address these in a timely manner.

The service had a ticketing maintenance system so all work could be managed, prioritised and appropriately addressed.

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.

Staff were recruited safely to the service. This included requesting and receiving references from previous employers, right-to-work documentation and Disclosure and Barring Service (DBS) checks. DBS checks are carried out to confirm whether prospective new staff had a criminal record or were barred from working with people at the time.

The service considered people’s needs and preferences when staff were recruited, and what personal and professional qualities staff could bring to their work. Staff received a comprehensive onboarding and induction, equipping them with the skills and knowledge to deliver support in line with the providers expected standards of care. A residential manager said, “Recruitment has been really good. We have taken on 4 new members of staff and the process in which they come in is really thorough. The meet and great at the start is so helpful. The induction process is 3 - 4 weeks and really in depth. Then they have supernumerary shifts so our recruitment process is robust so we get the right staff.”

We observed there were enough staff to meet people’s needs and staff were knowledgeable about people’s needs. We heard how staffing had previously been a challenge, but the provider and registered manager had put measures in place to make the necessary improvements. A residential manager told us, “Staffing was a big issue historically and we lost staff quite quickly. We hadn't had much recruitment focus as we had previously been fully staffed. However, now there is a skill mix here which is good and…the culture of the staff team is good. 8 months ago morale was low and there were a lot of managerial changes here. There was unease, but that has improved [significantly].”

Staff received regular opportunities to share and gather feedback at team meetings and individual supervision sessions. These included key themes which were covered on a rotational basis so staff remained skilled and up to date with internal policies and best practice guidance. The provider acted efficiently when they identified areas for improvement. A residential manager told us, “Our most recent supervisions were the most positive we have had.”

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.

There were clear roles, responsibilities and procedures around infection prevention and control that met current and relevant national guidance. Staff were trained and understood their role and responsibilities for maintaining high standards of cleanliness and hygiene in the premises and their own personal hygiene, including hand hygiene. Staff demonstrated a good understanding of infection control and prevention procedures.

The service was clean, tidy and free from odour across all units. We observed staff used and had access to supplies of personal protective equipment to help prevent and control the spread of infection.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. 

Person centred care plans were in place to support people with their health needs such as diabetes and epilepsy. Some people were prescribed medicines to be administered on a when-required basis for health conditions such as constipation, pain and anxiety. Guidance in care plans and protocols was in place. However, we identified some protocols which could have been more person centred. We shared this with the provider who took immediate action to resolve.   

Medicines were stored securely and at appropriate temperatures. There was an adequate stock of prescribed medicines. 

Medicines were administered as prescribed. The records we reviewed provided assurance medicines were not being used to control people’s behaviour. The staff worked closely with local health agencies and the GP practice to support people with their medicines and health needs. Medicines were regularly reviewed by the staff from the local GP practice.  

There was a medicine policy and process to report and investigate medicine errors and incidents. Staff carried out medicine management audits to identify gaps and make improvements. The staff received training and were competency assessed to handle medicines safely.