Bradford District Care NHS Foundation Trust

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• 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 requires improvement. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

The ward was safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

However, we did find there were vacancies for nurses and some care plans were not as well written as others.

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.

We scored the service as 3. The evidence showed a good standard of care. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Leaders ensured safety was a top priority that involved everyone, including staff as well as people using the service. Staff told us they learned from incidents through debriefs involving patients, discussions in handover meetings, weekly reflective practice sessions and from learning shared by the trust. The ward had changed the way it conducted observations following an incident.

Leaders ensured incidents were appropriately investigated and reported. We reviewed incident records; staff reported incidents correctly and managers investigated when required. There had been one serious incident and staff and patients were debriefed and supported after this incident.

There had been no incidents requiring a duty of candour response. Staff understood the duty of candour and their requirement to be open and transparent and gave patients and families a full explanation if and when things went wrong.

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 patient was received to determine if the patient’s needs could safely be met. There was evidence within the care records that information had been reviewed to ensure that staff had the necessary information ready to receive an admission of a patient to the ward, for example information about risks and physical health.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. We could see that efforts were made to encourage the necessary professionals to attend multi-disciplinary meetings and that there was evidence of robust discharge plans being implemented which had led to safe and effective discharges of patients to the next stages of their treatment.

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 concentrate 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. There had been 11 safeguarding referrals from the ward, all relating to adults.

All staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Our review of records showed us that systems were working well and enabled all staff to submit alerts which would be reviewed and acted upon by other members of the team where necessary.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.

Staff followed safe procedures for children and other people visiting the service.

Patients said they felt safe on the ward. It was clear that where patient related safety incidents took place, staff took appropriate action to protect all patients and to prevent further incidents.

It was necessary for staff on the ward to use restraint on some occasions, but this was done so as a last resort and for as little time as possible. Staff had undertaken the necessary training to ensure that they carried out restraints safely and there were enough staff working on the ward to respond to these incidents where necessary. Over 12 months there had been 30 restraints recorded, 29 were classed as supportive and not full holds.

Staff evidenced a least restrictive approach through discussions and their actions. There were some blanket restrictions on the ward, but these were ward specific and there was a log that ensured they would be periodically reviewed. Some patients had specific restrictions placed on them, these were necessary and proportionate to their treatment. The ward did not use seclusion or long-term segregation.

We scored the service as 2. The evidence showed some shortfalls.The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint only after attempts at de-escalation had failed. The ward staff participated in the trust’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 looked at six patient risk assessments and risk management plans during the inspection. Staff involved patients in care planning and risk assessment, this was evident in some elements of each person’s care record. Not every patient wanted to, but each were encouraged to attend their multi-disciplinary team meetings and were offered a copy of their care plans.

Risk management plans were tailored to patients’ specific needs and correlated with their assessment. The care plans we reviewed were sufficiently detailed to inform staff how best to support people with complex health conditions. However, whilst sufficient, care plans did differ in terms of quality of information. For example, we reviewed the care plans for 2 patients who were type one diabetic. One care plan was an exemplar with detailed information to inform staff how to support the patient, and how to recognise if the patient might be about to have a diabetic attack. The second care plan was a lot less detailed and lacked information specific to the individual patient.

There was an effective audit system to review care plans and ensure they were sufficiently detailed and contained key information and guidance for staff. Audits we reviewed of care plans had identified issues and the ward manager addressed these with the staff in supervision.

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.

Staff did daily safety walks to assess the ward environment. We saw evidence of maintenance work being carried out a a result of issues identified during these checks.

Health and safety checks were carried out and were up to date; these included regular audits of ligature risks, fire safety equipment and procedures, portable appliance tests and patient and staff alarm systems.

Ward layout allowed staff to observe all parts of ward and there were staff working throughout the ward who were able to observe patients. There were potential ligature anchor points which staff had identified with risks being mitigated adequately. This was managed on an individual patient basis, such as through individual patient observations.

Staff had easy access to alarms and patients had easy access to nurse call systems. Records showed that staff responded to incidents quickly, staff said they felt well supported during incidents.

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

We scored the service as 2. The evidence showed some shortfalls. The service did not have enough qualified, skilled, and experienced staff.

The service had high vacancy rates for band five nurse with vacancies for 4.54 posts out of the budgeted 8.54 posts. These vacancies had been recruited to but those staff were not in post at the time of our assessment. The ward also carried vacancies for 1.69 band 2 and 3 health care assistants. This was a total of 7.92 whole time equivalent vacancies out of budgeted total of 22.99 staff or 34% of staff.

Establishment levels were set by the trust. Managers calculated and reviewed the number and grade of nurses, nursing assistants and healthcare assistants for each shift when planning rotas. The ward manager could adjust staffing levels according to the needs of the patients. Each location held daily safety huddles to assess staffing and consider any shortfalls.

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

The ward operated two shifts. Day shifts consisted of 2 qualified nurses and 3 health care assistants and night shifts consisted of 1 qualified nurse and 3 health care assistants. They were supported by the ward manager, occupational therapist and assistant who worked Monday to Friday.

We examined the actual number of staff required (this included numbers above the core shift rota) to the number working from 1 April 2025 to 30 September 2025. This was for reasons such as additional staff required due to patient individual observations. We found that during that timeframe the service required 525 individual registered staff shifts and 11 of these were not fulfilled. However, the service always had a nurse on duty throughout this period.

For the unregistered staff, the service required 1034 individual shifts and 24 of these were not fulfilled.

The total percentage of required shifts not covered for the service was 2.24%.

The trust did not use agency staff but used staff already employed by the trust as bank staff. There were no recorded incidents of patients missing leave or activities due to staff vacancies.

All mandatory training courses were compliant with the trust target of 80% apart from two courses. Two staff were shown as non-compliant for level 2 food safety but managers explained there was a recording error and this in fact only applied to one staff member. The other course, Oliver McGowan learning difficulty training had been recently introduced, and staff were booked to complete the course soon.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff adhered to infection control principles, including handwashing. They told us that they washed their hands to prevent infection, and that personal protective equipment was available.

All ward areas were clean, had good furnishings and were well-maintained. Managers had put in place audits to ensure staff cleaned all areas when required to do so and bedding and other soft furnishings were replaced according to the trust’s policy. Staff made sure cleaning records were up-to-date, and the premises were clean. We reviewed cleaning rotas and spoke with housekeeping staff who were able to show us up to date and comprehensive records. During the inspection we saw continuous cleaning activity, and the ward was clean and tidy.

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

We looked at seven patient prescription charts. Staff followed good practice in relation to medicines management and did this in line with their own and national guidance. The prescription charts we looked at for patients that were detained under a section of the Mental Health Act, complied with the necessary requirements of the Mental Health Act.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with National Institute for Health and Care Excellence (NICE) guidance, especially when the patient was prescribed antipsychotic medication. No patients were on high doses of antipsychotic medication, and all prescribing was within British National Formulary (BNF) limits.