CQC report explained · a residential care home
What the CQC found at Shaftesbury Bradbury Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from harm, risks were assessed and reviewed, medicines were managed safely and there were enough staff. Infection control arrangements and COVID-19 vaccination requirements were also checked.
- Effective?
- Good
- People's needs and choices were assessed and reflected in care plans. Staff had suitable training, people were supported with food and drink, and health needs were monitored.
- Caring?
- Good
- This key question was not inspected during this visit. The report says ratings for questions not inspected were carried over from the last inspection.
- Responsive?
- Good
- This key question was not inspected during this visit. The report says ratings for questions not inspected were carried over from the last inspection.
- Well-led?
- Good
- The home had stronger quality monitoring, open leadership and systems for involving people, relatives and staff. Leaders acted on incidents and followed up actions.
What inspectors found, March 2022
Livability Bradbury Court was rated Good after inspectors found safer medicines management, effective care and stronger leadership, although this was a focused inspection.
Inspectors visited unannounced on 2 February 2022. They spoke with four people and five staff, reviewed four care records and medicines records, and checked staff recruitment and management documents.
The home was rated Good for Safe, Effective and Well-led. Inspectors found people were protected from harm, medicines were managed safely, staffing was sufficient, care plans reflected people's needs and staff had suitable training.
The inspection also looked at infection prevention and control, including COVID-19 vaccination requirements. Inspectors found the home was meeting the requirements they checked and supported visits from relatives.
This was a follow-up focused inspection after a 2019 inspection rated the service Requires Improvement and found breaches about medicines and quality monitoring. Inspectors found improvements had been made and the home was no longer in breach.
Safer medicines
The home had improved its medicines systems since the previous inspection. Medicines were counted and checked after each round, and staff training and competency were reviewed.
“All medicines were counted and audited following each medicines round to ensure that they had been administered correctly and people received their medicines as prescribed.” from the report
Enough staff
Inspectors found enough care staff to keep people safe. People said staff responded fairly quickly when they needed help.
“There were sufficient care staff deployed to keep people safe.” from the report
Skilled staff
Staff had training, supervision and experience relevant to people's needs. New staff completed an induction and shadowed experienced staff before working alone.
“Care staff had the appropriate skills and training.” from the report
Accessible environment
The home was adapted for people's physical needs. Communal areas were accessible to wheelchair users, and rooms had en-suite facilities and kitchenettes.
“Communal areas were spacious and easy to access independently by people using wheelchairs.” from the report
People involved
People took part in meetings about their care and activities. A person chosen by residents represented their views in meetings with the provider.
“People participated in regular meetings and a person appointed by people who used the service attends meetings with the provider to raise any issues relevant to people living at Bradbury Court.” from the report
Staff survey follow-up
minorThe manager had carried out a staff survey, but its analysis was not complete when inspectors visited. Families may wish to ask what the results showed and what action followed.
“The registered manager told us that they did a staff survey in January 2022. However, the analysis of this survey had not been completed at the time of our inspection.” from the report
- 01What did the January 2022 staff survey show, and has its analysis now been completed?
- 02How are medicines counted, audited and checked today, and how are any errors followed up?
- 03How will my relative be involved in care plan reviews and decisions about activities?
- 04How will you support my relative to use the accessible areas and take part in the local community?
- 05Which Caring and Responsive ratings from the previous inspection still apply, and when will those areas next be assessed?
This was a focused inspection of Safe, Effective and Well-led, including infection prevention and control; Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 11 March 2022 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, December 2019
Rated Requires Improvement; inspectors found kind, person-centred care, but medicines were not always managed safely and learning from errors was weak.
This was an unannounced inspection on 25 September 2019. Inspectors included an inspector, a pharmacist and two experts by experience. They spoke with 13 people, one relative and six staff, and checked care, medicine, recruitment and management records.
The main safety concern was medicines. There had been eight medicine errors in the previous 12 months. Some staff were not suitably trained or competent to manage certain high-risk medicines. The home also did not investigate errors deeply enough to prevent them happening again.
People were generally treated with kindness and respect. Their choices, privacy, cultural needs and independence were supported. Care plans were reviewed, meals met people's needs and people were supported with activities, visitors and healthcare.
The overall rating was Requires Improvement. Safe, effective and well-led were also Requires Improvement. Caring and responsive were Good. The previous overall rating was also Requires Improvement, and the report says enough improvement had not been made.
Kind and respectful care
People said staff respected their privacy and dignity. Staff supported people to make choices and remain as independent as possible.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Cultural and religious needs
The home supported people to follow their religious practices and attend places of worship. Menus also included options for cultural and religious needs.
“People were supported to visit their places of worship.” from the report
Personalised support
Care plans recorded people's views, choices and needs. People chose their meals, activities and clothing, and their preferred gender of care worker was respected.
“People received person centred care. We observed a range of practices that reflected this.” from the report
Accessible information
Information was provided in formats such as pictures, gestures, video, audio and large print. The building included features to support people with visual impairments.
“Information was presented in different formats to enable people to communicate to the best of their abilities.” from the report
Food and healthcare
People's dietary needs were recorded and understood by staff. The home worked with healthcare professionals, including dietitians and speech and language therapists.
“There were arrangements to ensure people's nutritional needs were met.” from the report
Medicine errors
seriousThere had been eight medicine errors in the previous 12 months. Six involved medicines that should have been given from their original packaging, creating a risk to people's safety.
“The service was experiencing high level of medicines errors. Eight errors had been detected within the last 12 months.” from the report
Staff competence with medicines
seriousSome staff were not suitably trained and competent to manage high-risk medicines and medicines supplied in original packaging. This was a breach of Regulation 12.
“Some staff responsible for the management and administration of medication were not suitably trained and competent.” from the report
Limited learning from incidents
seriousMedicine errors were investigated, but the focus was mainly on the individual staff member involved. Wider organisational causes were not properly considered, making repeat errors more likely.
“We judged this approach made recurrences more likely because consideration was not given to organisational processes and other contributory factors that could have led to errors.” from the report
Staffing shortages
needs fixingThe home had staff shortages and relied heavily on agency workers. Some people said there could be more staff in the evenings and that they sometimes waited for the doors to be answered.
“There could be more staff in the evenings. Staff are a bit rushed” from the report
Health Action Plans
needs fixingPeople with learning disabilities did not have Health Action Plans. Inspectors said these could help prompt consistent support for their health needs.
“Less positively, people with learning disabilities did not have a Health Action Plan (HAP).” from the report
- 01What changes have been made to prevent errors with high-risk medicines and medicines supplied in original packaging?
- 02How are staff now trained and assessed as competent to administer these specific medicines?
- 03How do you investigate medicine errors, including wider causes such as staffing, processes and equipment?
- 04How many permanent, bank and agency staff are currently working on each shift, especially evenings and weekends?
- 05Have Health Action Plans now been completed for people with learning disabilities, and how are they reviewed?
This was an unannounced inspection prompted in part by concerns about medicines and staffing; inspectors considered all five key questions and looked at both the premises and the care provided. This explanation was written from the published report of 24 December 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 Shaftesbury Bradbury Court
6 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- March 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- March 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2016Goodstayed GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- July 2015Goodup from Requires improvementSafe: GoodEffective: GoodResponsive: Requires improvement
- April 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- July 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- February 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 17 November 2010.
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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