Bradford District Care NHS Foundation Trust

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

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.

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 service had a culture of safety, based on openness and transparency. They listened to concerns about safety and investigated and reported safety events. All staff knew what incidents to report and how to report them through an electronic incident reporting system.

We reviewed a sample of incidents and saw that staff knew what incidents to report and how to report them. Staff received feedback from investigation of incidents. This included sharing feedback through regular meetings and by email.

There was evidence of learning from incidents. For example, following an incident arising from a patient going absent without leave staff had completed an immediate fact-finding exercise, identified learning for discussion from staff and implemented immediate actions. Managers had then implemented some additional training for staff around searches to prevent a recurrence of the incident.

The Trust had implemented the Patient Safety Incident Response Framework (PSIRF) which is the NHS approach for responding to patient safety incidents to facilitate learning and improve patient safety. There had been no incidents within in the past 12 months that meet the criteria for a Patient Safety Incident Investigation (PSII).

Learning from incidents was shared via quality and safety meetings, and meeting minutes showed that managers completed Local Learning Reviews in response to incidents with actions implemented where appropriate. Safety alerts with information about lessons learned from incidents within the service and elsewhere in the Trust were routinely sent out to all staff.

Staff understood the duty of candour and could provide examples of when they had followed the duty of candour process. They were open and transparent, and gave patients and families a full explanation if and when things went wrong.

There were no reported incidents that met the duty of candour threshold in the last 12 months. Nevertheless, the Duty of Candour process was embedded within the trust’s Patient Safety Incident Response Framework (PSIRF), with oversight from a Mortality Duty of Candour Improvement Facilitator and the Patient Safety Executive Panel.

Staff were debriefed and received support after a serious incident.

Risk assessments were regularly reviewed and updated after incidents. Care plans were person-centred and included clear therapeutic goals.

The service worked with healthcare partners to ensure safe transitions of care, in which safety was well managed and monitored. The 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. Safety and continuity of care was a priority throughout patient’s care journey. This happened through a collaborative, joined-up approach to safety that involved patients, staff and other partners in their care.

There was a weekly single point of access meeting that took place weekly to consider bed management across the West Yorkshire Provider Collaborative area which was attended by senior clinicians from each provider. Managers told us this enabled more effective use of beds to alleviate pressure in areas with higher demand. They also said this ensured that service users referred from prison had access to moretimelyadmission for assessment and treatment.

Consultants within the service completed assessment to determine patient’s suitability for the unit. They gathered information about the individual’s background, current presentation, risks and history. Assessments were completed with input from the ward manager and the trust’s transitions team.

Each patient was allocated a named nurse and a support worker on admission. Those patients we spoke with knew who these were and said they could contact them for support.

Care records and staff interviews demonstrated that staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care throughout their pathway. Ward rounds and discharge meetings were routinely held for patients. The service invited external partners to these meetings and worked in partnership with external organisations to support and facilitate safe transitions to and from the service. The trust’s transition team worked alongside ward staff to support discharge. Staff sent discharge summaries, including detailed medication information, to patient’s GP, community pharmacy, and other relevant healthcare providers to ensure continuity of care and safe transition back into the community.

The service worked with patient and healthcare partners to keep people safe. Patients said that they felt supported by staff and that they felt safe on the wards. They said that they felt able to share any worries or concerns with staff.

Staff shared key information to keep patients safe when handing over their care to others during morning huddles. This included updates on the previous 24 hours, change in presentation, incidents, medical appointments, physical health needs and any changes to the care plan.

Data provided by the service showed that there had been 6 safeguarding referrals during the last 3 months: 4 on Ilkley ward and 2 on Baildon ward. We reviewed 3 safeguarding referrals and saw there were effective systems, processes and practices in place to make sure that people were protected from abuse and neglect. Each referral was submitted in time and there was evidence of very detailed oversight of safeguarding alerts by managers. Referrals were reviewed by team leaders, clinical leads, area managers and the compliance team, with a record of the referral, actions, and progress recorded.

Staff received training specific for their role on how to recognise and report abuse. Training compliance for all safeguarding children and adult modules was above 80%. The Education and Training team within the trust were currently reviewing and updating training requirement. One change that had resulted from this review to increase Level 3 Children's Safeguarding training frequency from every three years to annually for some clinical staff

There was a safeguarding policy in place which was subject to regular review. Staff were knowledgeable about safeguarding and knew how to raise a concern when required. They were able to identify different forms of abuse, and the signs associated with these. Staff attended regular meetings where important information and lessons learned were shared. Staff were observed having a caring and compassionate approach when engaging with people.

There was a safeguarding team within the trust who provided structured support through supervision, consultation, and training tailored to inpatient roles, ensuring staff were equipped to identify and respond to safeguarding concerns.

Safeguarding referrals were discussed in Quality and Safety meetings, with any actions and learningidentifiedshared. Oversight of this was also held by West Yorkshire Provider Collaborative, with safeguarding concerns shared as part of quarterly contract reporting processes.

Staff followed safe procedures for children visiting the ward and there was an up-to-date child visiting policy in place. Where appropriate staff sought agreement from the local authority children’s services prior to arranging visits from children and visits usually took place in a visiting room outside the wards.

Patient told us that they had been involved in their risk assessment and knew what their risks were. Some patients said they had been restrained during their time on the ward.

The service worked with patients to fully understand and manage risks. Staff we spoke with knew about and dealt with any specific risk issues relevant to individual patients.

Care provided met people’s needs and was safe, supportive and enabled patients to do the things that mattered to them. We reviewed 8 sets of care records during the assessment. These showed that staff involved patients in care planning and risk assessments. Staff completed risk assessments for each patient on admission, using a recognised tool, and reviewed this regularly, including after any incident.

Patients were invited to participate in multidisciplinary team reviews and offered copies of their care plans. Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties.

Blanket restrictions were only imposed where necessary to meet the needs of the patients and maintain the safety of patients and staff or that they were being kept under regular review when imposed. Each ward had a blanket restrictions log this was regularly reviewed with individual restrictions removed where no longer required. This information was displayed in communal areas for service users.The Blanket restriction policy was under review, and the new policy and restricted item register was due for implementation in October 2025. Managers told us this included a review of mobile phones and other devices.

We reviewed physical intervention data for the previous 2 years and saw that levels of restraint were low. Staff and managers told us nearly all incidents were managed with use of verbal de-escalation and engagement.They said they used restraint as a last resort and only after all efforts at verbal de-escalation had failed. Training on the management of aggression and violence was provided by the Trust to all clinical inpatient staff with this training having a focus on trauma-informed practice and safe de-escalation.

There were 5incidents of rapid tranquilisation reported during the last 12 months. All incidents took place on Thornton ward and related to two patients.Managers described how they monitored the use of restraint and rapid tranquillisation through different arrangements and meetings. Themes and trends were triangulated and reviewed within the Trust Quality and Operational Accountability Groups and into the Positive and Proactive Group where professional,operationaland clinical leads progress the Trusts strategicobjectiveto reduce the use of restrictive interventions and practice.The Positive and Proactive Group reports into The Trust Quality and Safety Committee and the Mental Health Legislation Committee up into Board, thus givingWard to Board visibility and oversight of use of all restrictive interventions and work to reduce their use. Any incidents of rapid tranquilisation would also be discussed within the service Quality and Safety meeting.Managers told us this monitoring helped to mitigate the immediate impacts and proactively mitigate and reduce likelihood of further incidents and distress.

People told us they felt safe on the ward, and the environment was safe, clean and well- maintained. Staff were aware of the importance of completing safety checks of the environment and equipment. Staff were able to describe a range of security procedures on each ward including regular checks and counts of potentially hazardous items and environmental checks. There was an allocated staff member dedicated to ward security each shift.

There were copies of the ligature risk assessment on each ward to support all staff. Managers ensured new starters familiarised themselves with this during induction and orientation.

Managers completed annual assessments of the environment with interim reviews triggered by incidents or environmental changes. There was evidence of ongoing review of the environmental risk assessments with appropriate action being taken. For example, staff had identified a potential climb point within a courtyard and an outside water supply issue, both of which had been resolved promptly. There was a Ligature Environment Risk and Safety (LERS) Group within the trust, which reviewed incidents and coordinated environmental changes where these were needed.

Staff and managers reviewed individual patient risks regularly, sharing updates via handovers and safety huddles to ensure staff followed observation protocols to try and ensure a safe care environment.

Staff were observed completing observations in communal areas and corridors depending on the location and observation level of each person.

Wards had a range of communal areas including lounges, and activities of daily living kitchens. Each ward had a dining room with a servery used to serve meals. Wards were accessible for patients with mobility needs and disabled bathrooms were available on the wards.

All staff carried panic alarms. There were alert panels in rooms and corridors including staff areas so that staff could identify where assistance was needed. Patient bedrooms also had nurse call alarms

Staff carried out daily safety checks of specialist equipment. This included ligature cutters and emergency equipment.

The service had a security induction for all staff which had to be completed prior to staff being issued with keys. This process and documentation for this induction had recently been revised to include provisions for staff who may be moved from another service at short notice.

The service made sure there were staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. They worked well together to provide safe care which met people’s individual needs. The Trust used the Enhanced Therapeutic Observation and Care (ETOC) and Mental Health Optimal Staffing Tool (MHOST) led by NHSE to determine staff numbers. Managers accurately calculated and reviewed the number of support workers needed for each shift. On Baildon and Ilkley ward, baseline staffing numbers were 2 registered nurses and 3 support workers for day shifts. On night shifts this was 1 registered nurse and 3 support workers. On Thornton ward there were 5 registered nurses and 2 support workers on day shifts, and 1 registered nurse and 4 support workers on night shifts. Staff we spoke with generally told us staffing numbers were sufficient and enabled them to safely care for patients. Managers regularly reviewed and adjusted staffing levels and skill mix during weekly meetings and identified and arranged cover for any gaps in leadership. There were also daily ward manager huddles to identify any risks and challenges for the next 24 hours, and to make any necessary changes to staffing. The Trust had stopped using agency health care support worker staff in 2024 and had carried an expansion of the staff bank cohort through new recruitment and transitioning of agency staff on to the staff bank. Managers told us this enabled them to ensure health care support workers receive consistent training and development. We reviewed 2 seclusion records, 3 seclusion care plans, and internal audits for the last 4 episodes of seclusion. There were several gaps within the records confirming whether medical reviews or independent multidisciplinary team reviews had taken place. However, these periods of seclusion had taken place several months prior to the inspection, and managers had identified this during their audits and taken steps to prevent a re-occurrence. Managers gave bank and agency staff a full induction prior to working on the ward. The Trust commenced roll out of Oliver McGowan training in the summer of 2025. The Oliver McGowan Mandatory Training is standardised training that was developed for ensuring staff receive learning disability and autism training appropriate to their role. Prior to Oliver McGowan the Trust had implemented a recognised Autism Awareness Training. Training compliance was 96% for Baildon ward, 92% for Ilkley ward, and 100% for Thornton ward. Staff had received and were up to date with appropriate mandatory training. The mandatory training was comprehensive and met the needs of patients and staff. Training modules included health safety and welfare, infection prevention and control, and Care Programme Approach, Clinical Risk, Formulation, Assessment and Management training. The organisational target for mandatory training was 80% except for Information Governance Training which was 95%. All training compliance was above 90% except for safeguarding training at around 80%, and most modules were over 95%. Managers reviewed training compliance during monthly quality and safety meetings and completed escalation reports highlighting areas of non- compliance The service had low vacancy rates across most staff bands with ward generally having 0, 1 or 2 vacant posts at each staff band. Turnover fluctuated monthly. Data for September showed a turnover of 6% on Baildon ward, 26% on Ilkley ward, and 10% on Thornton ward. Managers described how the relatively small staff teams within the service meant small workforce changes could alter the data. The service had low sickness rates. The average absence during the last 12 months was 5% for Baildon ward, 11% for Ilkley ward, and 6% for Thornton ward. Managers monitored sickness during fortnightly meetings and received support from People’s Services and the People Matters team within the trust to helped address long-term and frequent absences and maintain safe staffing levels.

The service assessed and managed the risk of infection. Staff followed good infection prevention and control procedures in line with organisational policy. This included the use of personal protective equipment. Patients did not raise any concerns about infection control. They told us that they felt safe in the environment and that all areas were cleaned regularly.

There were adequate supplies of personal protective equipment on the wards. Housekeepers visited the ward 7 days a week and followed a schedule of cleaning. Staff could contact their estates and facilities teams for any additional cleaning.

Staff completed regular environmental and infection prevention and control audits and where areas of improvement had been identified, appropriate action plans were in place.

Staff demonstrated a good knowledge of infection prevention and control. Staff followed the provider’s waste disposal processes with clinical and non-clinical waste discarded and stored appropriately.

During our tour of clinic rooms, we found that staff had recorded that they cleaned equipment after each patient contact. Equipment was labelled to show when it was last cleaned.

Staff followed systems and processes to prescribe and administer medicines safely. Staff we spoke with knew where to access relevant guidelines including the BNF (British National Formulary) and NICE (National Institute for Health and Care Excellence) guidelines. There were relevant medicines management policies in place which were comprehensive and reviewed regularly.

Prescribing across all wards was monitored by specialist mental health pharmacists who form an integral part of the multi-disciplinary team. Each ward had an assigned pharmacist and pharmacy technician to oversee all aspects of medicines management

On admission, pharmacists, and pharmacy technicians completed medicines reconciliation for each patient. Throughout the patient’s admission, they reviewed all prescribing to ensure it was safe, evidence-based, and compliant with local and national policies, procedures, and guidance. Any prescribing concerns were discussed with the ward’s medical team and consultant psychiatrist.

There was a trust wide medicines management group. A pharmacist attended quality and safety meetings and fed back information or identified concerns to managers from the trust wide medicines managements group.

Patients told us staff reviewed their medicines regularly and provided advice to them about these. Care records showed that staff recorded ongoing discussions with patients about the nature, purpose and potential side effects of their medicines. Staff made sure patients discussed their medicines during ward rounds and this gave patients the opportunity to ask questions or raise any concerns.

We reviewed 9 prescription charts. These were accurate and staff kept them up to date. There were treatment certificates in place where required.

We reviewed clinic rooms on all 3 wards and saw that staff stored and managed all medicines and prescribing documents safely.

The service ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines. Pharmacists completed medicines audits and provided reports to managers about any prescribing outliers. the service completed quarterly controlled drugs audits, sharing findings with ward managers and reported these through the trusts Medicines Management and Safety Group. Medicines management concerns were also escalated to the Clinical Board and Quality and Safety Committee where necessary to ensure oversight by senior leaders.

We reviewed a sample of clinical audits and saw that audit actions were recorded on a centralised document, with follow-up audits undertaken asrequiredbased on the outcomes.

Staff we spoke with understood the process for reporting medicines errors and medicines management incidents and did so using the trust’s incident reporting system.

There were a medicines management policy and standard operating procedures in place relating to relevant areas of medicines management.