CQC report explained · a residential care home
What the CQC found at Bradbury House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2020
Requires Improvement; inspectors found kind and effective care, but ongoing risks, incomplete care records and weak oversight remained.
This was a two-day, unannounced first-day inspection prompted by concerns about abuse, staffing and medicines. Inspectors observed care, checked records and medicines, spoke with staff, professionals and one relative, and reviewed the home's systems.
The home was rated Good for Effective and Caring. Staff were described as kind and trained, people had access to healthcare and activities, and there was enough staff on duty during the inspection. Medicines systems had improved, but errors had occurred.
The home was rated Requires Improvement for Safe, Responsive and Well-led. Risk plans did not always give staff clear instructions, care plans lacked detail, and not all incidents were reviewed or reported properly. The home remained in breach of Regulation 12, and this was the second Requires Improvement rating in a row.
Kind and respectful support
Inspectors saw staff use patience, kindness and different ways to engage with people. Staff respected privacy and encouraged people to be as independent as possible.
“getting to know them [people] by reading care plans and talking to parents make people feel they matter.” from the report
Staff training and support
Staff had mandatory and specialist training, regular supervision and induction arrangements. A local authority trainer reported strong staff engagement and knowledge.
“I have noticed and am pleased to report that staff engagement, interest, knowledge and passion for delivering quality support is evident at very high levels.” from the report
Improved effectiveness
The Effective rating improved to Good. Health action plans, emergency healthcare information and hospital passports were in place.
“At this inspection this key question has now improved to good.” from the report
Communication support
The home was developing communication passports and used a Makaton board to help staff understand and support people who used signs or symbols.
“A Makaton board in the foyer of the building gave staff simple signs and symbols to help with effective communication.” from the report
Risk plans were not clear enough
seriousSome risk plans did not explain clearly how staff should reduce risk or calm situations. Staff used different approaches, which placed people, staff and others at risk of harm.
“The risk reducing measures lacked guidance and did not give staff clear instructions on how to de-escalate situations.” from the report
Care plans lacked detail
needs fixingExisting care plans did not consistently reflect people's current needs. New, more person-centred plans were being developed but were not yet in place.
“The existing care plans lacked detail and did not reflect people's needs.” from the report
Incidents were not fully reviewed
seriousOnly two of nine reviewed incidents had been reviewed by a manager. One incident involving people and staff being physically challenged was not reported to safeguarding or CQC.
“Of the nine incident reports only two were reviewed by a manager.” from the report
Limited fresh food
needs fixingFood supplies were adequate, but most food was processed and people had limited access to fresh fruit and vegetables. Staff needed support to prepare fresh meals.
“most food was processed and people had limited access to fresh fruit and vegetables.” from the report
Food storage and cleaning
minorSome opened food was not dated and the fridge needed cleaning. Boards used for preparing meals also needed replacing.
“We noted not all foods were dated when opened and the fridge needed cleaning.” from the report
- 01What has changed in the risk plans for people who become anxious or frustrated, and how do you check that all staff follow the same approach?
- 02How are current care plans written with input from families, and when will the new person-centred plans be completed?
- 03How are incidents now reviewed, analysed and reported to safeguarding and CQC when required?
- 04What checks are now made on medicines, including medicines given in food, and how is staff competency assessed?
- 05What fresh meals and meal choices are now available, and how do you check food dating, fridge cleaning and kitchen equipment?
This was a full follow-up inspection covering all five questions, with observations, record checks and discussions with staff, professionals and one relative. This explanation was written from the published report of 31 January 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2019
Rated Requires Improvement; inspectors found risks, safeguarding and management systems were not reliable enough to keep people safe.
The inspection took place on 1 and 2 July 2019. It was a focused inspection after concerns about people's safety. The inspector spoke with eight staff, observed care, and reviewed five people's care plans and other records.
Inspectors found that risks, accidents and injuries were not consistently assessed, investigated or recorded. Safeguarding referrals were not made for every allegation. Some staff were supporting people with behaviours described as challenging without the right training.
People's freedom was sometimes restricted without all the required mental capacity assessments or legal authorisation. Staff induction, training records and supervision were also not reliable. A recently appointed manager had started an improvement plan, but the home still needed to make substantial improvements.
The overall rating fell from Good at the previous inspection to Requires Improvement. This inspection only assessed Safe, Effective and Well-led. The ratings for Caring and Responsive were carried forward from the previous comprehensive inspection.
Recruitment
Inspectors found that recruitment procedures had been properly followed.
“Recruitment procedures were well managed.” from the report
Safeguarding knowledge
Staff understood how safeguarding procedures should work, even though the procedures were not always followed.
“comments from staff showed they had a good understanding on how to apply safeguarding procedures.” from the report
Medicine training
Staff had attended medicine management training to support their competence in giving medicines.
“The staff attended medicine management training to ensure their competency with administering medicines” from the report
Improvement work
The recently appointed manager had identified areas needing improvement and was organising audits and an improvement plan.
“The manager was recently appointed and they had an oversight on the improvements needed.” from the report
People's feedback
People's views were collected through monthly meetings, using pictures and words to record agreements.
“The feedback from people was gathered through monthly resident's meetings.” from the report
Risks and injuries
seriousRisk assessments were not always up to date or reviewed after changes. Injuries and incidents were not consistently investigated, so staff did not always have clear guidance to prevent harm.
“Risks were not well managed and placed people at potential harm.” from the report
Safeguarding referrals
seriousThe home did not make a safeguarding referral for every allegation of abuse. This placed people at potential risk of harm.
“Safeguarding referrals were not made for all abuse allegations.” from the report
Staff training
needs fixingSome new staff did not receive the expected induction, and some staff supported challenging behaviour without the appropriate training. The training records were not accurate or up to date.
“The training matrix was not accurate and up to date.” from the report
Restrictions on freedom
seriousSome people had restrictions or one-to-one or two-to-one support without all the required capacity assessments and legal safeguards. This meant care was not always the least restrictive option.
“People were not fully supported to have maximum choice and control of their lives.” from the report
Management oversight
seriousPolicies were not consistently followed, audits did not identify all the problems, and CQC was not notified of every reportable incident.
“Systems were either not in place or robust enough to demonstrate safety was effectively managed.” from the report
- 01What risk assessments and action plans are now in place for my relative, and how often are they reviewed after an incident or change in need?
- 02How are safeguarding allegations, unexplained injuries and accidents reported, investigated and followed up?
- 03Have all staff supporting people with behaviours described as challenging completed positive behaviour management training?
- 04What induction, supervision and competency checks do new staff complete before working independently?
- 05What mental capacity assessments, best-interest decisions and DoLS authorisations are in place for any restrictions on my relative's freedom?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 9 August 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Bradbury House
5 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- January 2020Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- May 2019Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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